10.5826/dpc.1303a168
Introduction: Studies have suggested that botulinum toxin A may improve skin quality, and application protocols using hyper-diluted doses of botulinum toxin (microdosing) have been studied as a way to achieve therapeutic goals without fully paralyzing the targeted muscles.
Objectives: To evaluate the effects of a combined protocol utilizing both the standard dosing and the microdosing of AbobotulinumtoxinA for the improvement of skin quality, measured by objective and subjective measurements.
Methods: Thirty patients were treated with botulinum toxin using both the standard technique and the microdosing technique. Objective (Sebumeter®, Mexameter® and digital dermoscopy pictures) and subjective (Global Aesthetic Improvement Scale and a clinical scale for evaluating the quality of facial skin) measurements of the effects in the treated areas were taken to assess the efficacy of the treatment.
Results: Digital dermoscopy showed a marked reduction of erythema and telangiectasias. Erythema and telangiectasias improved both on objective and subjective measurements. Skin oleosity, static rhytids, papules and pustules and enlarged pores improved on subjective measurements. Patient satisfaction was high (93%) despite the high rate of adverse events (56%).
Conclusions: The combined application of standard doses and microdoses of AbobotulinumtoxinA is effective in improving the overall quality of facial skin. The effects on erythema and telangiectasias suggest that it is an effective treatment option for patients with erythematotelangiectatic rosacea. When applying microdoses of botulinum toxin in the lower and mid-face, the doses and pattern of injection should be customized for each patient to reduce the occurrence of adverse events.
text/xml
2160-9381
2994
en
Vitor Costa Fabris
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
telangiectasias
Subjective and Objective Measurements of the Facial Effects of Microdoses of Botulinum Toxin
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-11-17
2023-07-31
2023-08-24
e2023168
Dermatol Pract Concept
Introduction: Studies have suggested that botulinum toxin A may improve skin quality, and application protocols using hyper-diluted doses of botulinum toxin (microdosing) have been studied as a way to achieve therapeutic goals without fully paralyzing the targeted muscles.
Objectives: To evaluate the effects of a combined protocol utilizing both the standard dosing and the microdosing of AbobotulinumtoxinA for the improvement of skin quality, measured by objective and subjective measurements.
Methods: Thirty patients were treated with botulinum toxin using both the standard technique and the microdosing technique. Objective (Sebumeter®, Mexameter® and digital dermoscopy pictures) and subjective (Global Aesthetic Improvement Scale and a clinical scale for evaluating the quality of facial skin) measurements of the effects in the treated areas were taken to assess the efficacy of the treatment.
Results: Digital dermoscopy showed a marked reduction of erythema and telangiectasias. Erythema and telangiectasias improved both on objective and subjective measurements. Skin oleosity, static rhytids, papules and pustules and enlarged pores improved on subjective measurements. Patient satisfaction was high (93%) despite the high rate of adverse events (56%).
Conclusions: The combined application of standard doses and microdoses of AbobotulinumtoxinA is effective in improving the overall quality of facial skin. The effects on erythema and telangiectasias suggest that it is an effective treatment option for patients with erythematotelangiectatic rosacea. When applying microdoses of botulinum toxin in the lower and mid-face, the doses and pattern of injection should be customized for each patient to reduce the occurrence of adverse events.
Vitor Costa Fabris
2023/07/31
10.5826/dpc.1303a168
e2023168
Brazilian Center for Studies in Dermatology, Porto Alegre, Rio Grande do Sul, Brazil.
2160-9381
telangiectasias
en
e2023168
Shamloul G, Khachemoune A. An updated review of the sebaceous gland and its role in health and diseases Part 1: Embryology, evolution, structure, and function of sebaceous glands. Dermatol Ther. 2021;34(1):e14695. DOI: 10.1111/dth.14695. PMID: 33354858.
Subjective and Objective Measurements of the Facial Effects of Microdoses of Botulinum Toxin
https://dpcj.org/index.php/dpc/article/download/2994/2201
      Subjective and Objective Measurements of the
      Facial Effects of Microdoses of Botulinum Toxin
                       Doris Hexsel1,2, Indira Valente-Bezerra1,2, Gabriela Mosena1,2,
                           Maria Antonia Oakim Mourao1, Vitor Costa Fabris1


1 Brazilian Center for Studies in Dermatology, Porto Alegre, Rio Grande do Sul, Brazil
2 Hexsel Dermatologic Clinic, Porto Alegre, Rio Grande do Sul, Brazil



Key words: Botulinum Toxin, microdoses, skin quality, telangiectasias, erythema
Citation: Hexsel D, Valente-Bezerra I, Mosena G, Oakim Mourao MA, Costa Fabris V. Subjective and Objective Measurements of the
Facial Effects of Microdoses of Botulinum Toxin. Dermatol Pract Concept. 2023;13(3):e2023168. DOI: https://doi.org/10.5826
/dpc.1303a168
Accepted: February 6, 2023; Published: July 2023
Copyright: ©2023 Hexsel et al. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: Galderma donated the AbobotulinumtoxinA used in this study. The study was founded by the principal investigator, Dr Hexsel.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Doris Hexsel, MD, Brazilian Center for Studies in Dermatology 1592 Dom Pedro II, 90550-141, Porto Alegre,
Rio Grande do Sul, Brazil. Phone: + 55 51 3026.2633 Email: doris@hexsel.com.br
Ethical Statement: This study was approved by the local Ethics Committee of Moinhos de Vento Hospital in Porto Alegre, Brazil and
followed the Good Clinical Practices, the Declaration of Helsinki protocols and all national regulations.




  ABSTRACT             Introduction: Studies have suggested that botulinum toxin A may improve skin quality, and applica-
                       tion protocols using hyper-diluted doses of botulinum toxin (microdosing) have been studied as a way
                       to achieve therapeutic goals without fully paralyzing the targeted muscles.
                       Objectives: To evaluate the effects of a combined protocol utilizing both the standard dosing and the
                       microdosing of AbobotulinumtoxinA for the improvement of skin quality, measured by objective and
                       subjective measurements.
                       Methods: Thirty patients were treated with botulinum toxin using both the standard technique and
                       the microdosing technique. Objective (Sebumeter®, Mexameter® and digital dermoscopy pictures)
                       and subjective (Global Aesthetic Improvement Scale and a clinical scale for evaluating the quality of
                       facial skin) measurements of the effects in the treated areas were taken to assess the efficacy of the
                       treatment.
                       Results: Digital dermoscopy showed a marked reduction of erythema and telangiectasias. ­Erythema
                       and telangiectasias improved both on objective and subjective measurements. Skin oleosity, ­static
                       rhytids, papules and pustules and enlarged pores improved on subjective measurements. Patient
                       ­
                       ­satisfaction was high (93%) despite the high rate of adverse events (56%).




Original Article | Dermatol Pract Concept. 2023;13(3):e2023168                                                                         1
                         Conclusions: The combined application of standard doses and microdoses of AbobotulinumtoxinA
                         is effective in improving the overall quality of facial skin. The effects on erythema and telangiectasias
                         suggest that it is an effective treatment option for patients with erythematotelangiectatic rosacea.
                         When applying microdoses of botulinum toxin in the lower and mid-face, the doses and pattern of
                         injection should be customized for each patient to reduce the occurrence of adverse events.




Introduction                                                         treatment with botulinum toxin in the upper face (glabellar,
                                                                     periorbital or forehead rhytids) and the presence of either
Botulinum Toxin Type A (BTX-A) has been used for over                rosacea (any kind), facial erythema, oily skin, enlarged pores
30 years to treat wrinkles and facial lines [1]. Injections of       or acne (any grade). Exclusion criteria included pregnancy
BTX-A are a simple, rapid, effective and safe method to im-          or lactation, active infection on the treated areas, and having
prove the appearance of patients. Long term repeated treat-          undergone previous invasive surgical procedures on the face,
ments with BTX-A on the face treat dynamic rhytids and               BTX-A treatment on the face less than 6 months before the
have additional positive effects, such as repositioning beauty       study, or treatments to improve the overall quality of the skin
defining facial structures (eg the eyebrows) and preventing          less than 3 months before the study (eg chemical peelings,
static rhytids [2,3].                                                fillers, radiofrequency therapy, microfocused ultrasound).
    New off label indications for BTX-A are being explored,
including the treatment of facial erythema, facial flushing,         Assessments
and acne [4-8]. One technique currently being studied is the         The primary outcomes of this study were the clinical im-
microdosing of BTX-A, which is the injection of multiple             provement in skin quality, the percentage of patients that im-
microdroplets of hyper-diluted botulinum toxin into the der-         proved in the Global Aesthetic Improvement Scale (GAIS),
mis or in the interface between the dermis and the superficial       and the frequency of adverse events. Secondary outcomes
subcutaneous. The lower concentrations and lower doses               were patient satisfaction and changes in facial erythema, in
utilized in the microdosing technique are able to improve            skin oiliness, and in clinical characteristics of the skin as-
facial aesthetics while maintaining the muscular function in         sessed by digital dermoscopy.
the treated areas [9].                                                   Patients were evaluated at baseline/procedure (day 1),
                                                                     at touch up (day 21) and at two follow up visits (days 56
Objectives                                                           and 84). Skin quality was evaluated using a non-validated
                                                                     clinical scale developed by the researchers for this study,
This study was designed to evaluate the effects of a com-            which rated the participants’ erythema, superficial static
bined protocol utilizing both the standard and the micro-            rhytids, enlarged pores, papules or pustules, and skin oiliness
dosing techniques of AbobotulinumtoxinA (Dysport ®)                  as imperceptible (0), mild (0.5) or marked (1). The sum of
injections for the improvement of skin quality (wrinkles,            all criteria classified the quality of the skin as great (0 to 1),
erythema, telangiectasias, enlarged pores, and oiliness), using      good (1.5 to 2.5), average (3 to 4) or bad (4.5 to 5).
objective and subjective measurement methods, and to assess              Photographs with a high-definition camera were taken
treatment safety and patient satisfaction.                           at all visits, with patients at rest and while performing dy-
                                                                     namic movements of the face. The pictures were taken at the
Methods                                                              same setting, with the same lighting, and by the same trained
                                                                     evaluator. They were used by three investigators (two derma-
Study Design                                                         tologists and one general practitioner) to clinically assess the
This was a prospective, single-center, open label trial. The         patients and to fill the GAIS. The GAIS was also self-reported
participants were recruited at a research center in Porto            by each patient at every visit following the procedure.
Alegre, Brazil, and provided written informed consent. This              Spectrometer measurements (Mexameter® MX 18) were
study followed the Good Clinical Practices, Declaration of           used to objectively evaluate the patients erythema. At every
Helsinki protocols and all national regulations, and was ap-         visit, four measurements were taken at the left side of the
proved by the local Ethics Committee of Associacao Hospi-            forehead and other four measurements were taken at the left
talar Moinhos de Vento.                                              malar area of the patients. The mean value of the measure-
    The main inclusion criteria were patients aged between           ments of each area was recorded for statistical analysis. Skin
18 and 70 years with at least one indication for cosmetic            oiliness was objectively quantified with Sebumeter® on the



2                                                                         Original Article | Dermatol Pract Concept. 2023;13(3):e2023168
forehead, chin, and on the tip of the nose, always on the
midline of the face.
    Digital dermoscopy was performed with Medicam®
(FotoFinder Body Studio ATBM Master®, FotoFinder
Systems GmbH). Pictures were taken with polarized and
non-polarized lights 1cm lateral to the left alar-facial sulcus
at 20x magnification, using an open front cap to avoid com-
pression of the superficial vessels of the skin. The pictures
were analyzed by the evaluators to assess the presence of
erythema, oily skin, enlarged pores and telangiectasias, using
their overall clinical impression to grade them as “improved”
or “not improved”.
    Objective measurements were taken after the patients
rested for at least 10 minutes in a climatized room at con-
trolled temperature (22±2°C).
    Adverse events were evaluated at every visit. Patients filled
a satisfaction questionnaire at every visit after the procedure.

Procedure
All patients were simultaneously treated with the standard
technique for at least one indication in the upper face (gla-
bellar, forehead or periorbital rhytids) and with the micro-
dosing technique.
    For the standard technique, 300 units of Abobotulinum-
toxinA (Dysport®) were reconstituted in 1.2mL of 0.9% sa-
                                                                    Figure 1. Injection points for the microdoses of Botulinum Toxin.
line solution for a concentration of 250U/mL (2.5U/0.01ml)
                                                                    The 100 points of injection were distanced 1cm from each other,
and applied in intramuscular injections using an ultra-fine         were applied as symmetrically as possible and were evenly distrib-
0.3cc needle (30G). The number of units of botulinum toxin          uted between the left and right sides and the 3 thirds of the face.
per injection point and the location where the points were
applied varied according to the investigator’s clinical as-
sessment of the patients. The total dose applied in each area
was different for each patient, but always followed the in-         mean ± standard deviation (SD) or median and interquar-
ternational consensus recommendations [7,8]. Doses of 40U           tile range (IQR), depending on its distribution (evaluated
to 50U were used to treat the glabella, of 45U to 65U to            through histogram). The significance of the variation of
treat the periorbital area, of 5U to 15U to treat the forehead,     erythema levels measured by Mexameter® MX 18 and of
and of 10U to 15U to treat the chin. The total dose utilized        sebum levels measured by Sebumeter® were tested using the
ranged from 120U to 210U for each patient.                          paired samples Wilcoxon test, as the variable’s distribution
    For the microdosing technique, an additional 0.75mL of          were not symmetric. Multiple testing corrections were not
0.9% saline solution was added to each 0.25mL of the pre-           performed, and so the p-values of the secondary outcomes
vious reconstituted toxin (2.5U/0.01mL solution), resulting         must be regarded as exploratory. The results were considered
in a final concentration of 0.625U/0.01mL. The microdoses           statistically significant when the P value was lower than 0.05.
were applied intradermally following a standardized proto-
col: an addition to the standard treatment, each patient re-
                                                                    Results
ceived an additional dose of 62.5U of Dysport® distributed
in about 100 points of injection (Figure 1) - approximately         Twenty seven of thirty participants completed all visits; none
20U to 25U in each third of the face. Each injection consisted      of the dropouts were motivated by adverse events. Demo-
of a volume of 0.01ml (0.625U) per injection site.                  graphic data of the participants is shown in Table 1.
                                                                        Figure 2 shows the changes in facial skin quality pre and
Statistical Methods                                                 post treatment as assessed by the clinical scale. In the final
Thirty patients were enrolled for this study through conve-         assessment, 56% of the patients improved their facial ery-
nience sampling. Statistical analysis to determine sample size      thema (initially present in 23 patients), 56% improved their
was not performed prior to the study. Data was described as         superficial static rhytids (initially present in 21 patients),



Original Article | Dermatol Pract Concept. 2023;13(3):e2023168                                                                       3
        Table 1. Demographic data (N = 30).                           41% improved their papules or pustules (initially present in
                                                                      19 patients), and 30% improved their enlarged pores (Ini-
 Characteristics
                                                                      tially present in 19 patients). Skin oiliness (initially present in
 Age, years mean (±SD)                             42.1 (±13.2)
                                                                      26 patients) was reduced in 70% of patients. Overall, 85%
 Gender, N (%)                  Female             28 (93.3%)
                                                                      of the subjects improved their final score on the scale.
                                Male               2 (6.7%)
                                                                          On the GAIS, 89% (24) of the patients improved when
 Race, N (%)                    Caucasian          29 (96.7%)
                                                                      assessed by the investigators, and 93% (25) self-reported an
                                Multiracial        1 (3.3%)
                                                                      improvement of their appearance. Only one patient reported
 Phototype, N (%)               II                 10 (33.3%)         “worsening of their appearance” by the end of the treatment,
                                III                19 (63.3%)         which was due to an adverse event (reduction of smile ampli-
                                IV                 1 (3.3%)           tude), but none had a worsening of their appearance accord-
 Smoking, N (%)                 Non-smokers        29 (96.7%)         ing to the investigators.
                                Smokers            1 (3.3%)               Out of the 28 patients, 16 (57%) had adverse events re-
                                                                      lated to the treatment. Eleven participants had an isolated
SD = standard deviation.




 Figure 2. Changes in skin quality according to the clinical scale.




4                                                                         Original Article | Dermatol Pract Concept. 2023;13(3):e2023168
adverse event, four had 2 adverse events and one had             facial erythema, and rosacea [6,10,11]. The generalizability
3 adverse events. Five different kinds of adverse events were    of the results of those studies, however, is limited due to the
observed: minor bruises (7 occurrences), eyebrow asymme-         heterogeneity in the population being studied, the distinct
tries (6 occurrences), reduction of smile amplitude (5 occur-    treatment protocols being evaluated, the assessment methods
rences), smile asymmetries (3 occurrences), and one case of      utilized to measure the outcomes and the different brands of
smile asymmetry associated with a difficulty of moving the       the BTX-A studied [6].
lower lip. Minor bruises had a median duration of 4 days,           Our results suggest that microdoses of Abobotulinum-
lasting from 2 to 7 days; eyebrow asymmetries and smile          toxinA can improve skin quality, especially malar erythema,
asymmetries had a median duration of 20 days, lasting from       starting 3 weeks from the treatment and maintaining the
14 to 43 days (not counting one outlier smile asymmetry          results for at least 12 weeks, as skin quality was improved
which lasted for 4 months); reductions of smile amplitude        when assessed by the clinical scale and by digital dermoscopy.
had a median duration of 60 days, lasting from 30 to 78 days.    This finding is in accordance with previous literature [5,6].
    Objective measurements of erythema on the malar                 It is noteworthy that digital dermoscopy revealed not
region (assessed in the 27 patients who completed the study)     only a reduction of the erythema, but also an improve-
showed a significant reduction (P = 0.041) of the median,        ment of the caliber of facial telangiectasias (Figures 3-5).
from 440 (IQR 382.5 to 479.25) pre-treatment to 409 (IQR         This improvement was evident on day 56 and persisted
364.5 to 458) on day 84. Statistical analysis of the measure-    until the end of the study. Telangiectasias have tradition-
ments of erythema on the forehead and of sebum on all re-        ally been treated with light-based therapies [12,13], but
gions assessed were not significant.                             it is postulated that BTX-A can improve them by mod-
    On the satisfaction questionnaire, 93% of the patients       ulating blood vessel dilation, as it inhibits the release of
reported an improvement of their appearance. 93% declared        acetylcholine from peripheral autonomic nerves of the
being satisfied with the treatment and 89% said they would       cutaneous vasodilatory system, by blockading substance
like to receive the same treatment again in the future.          P and calcitonin gene-related peptide (which acts as inflam-
    Table 2 shows the changes in skin quality as evaluated       matory mediators) [14], and by inhibiting mast cell degran-
by digital dermoscopy. Improvement on erythema and telan-        ulation (which releases proinflammatory c­ ytokines) [15].
giectasias was imperceptible on day 21, evident on day 56,       The digital dermoscopy evaluation performed in our study
and persisted until the end of the study. A subset of patients   revealed an evident reduction in the caliber of the telan-
worsened on day 21 and later improved when compared to           giectasias, an effect which persistent until the end of the
the baseline. The improvement in the caliber of the telangi-     study. This is a new finding which has not been reported
ectasias was greater on small caliber vessels and lasted until   in previous studies [6,11].
the end of the study.                                               Enlarged pores were evaluated with non-polarized
                                                                 light and without a liquid interface, as the lighting of the

Conclusions                                                      non-polarized light allowed better visualization of the pores.
                                                                 Our results suggest a reduction in the size of the pores in a
Several studies suggested that injections of microdoses of       subset of patients, but it is important to note that the ab-
BTX-A may be an effective procedure for the management           sence of a liquid interface makes it harder to reproduce the
of excess facial sebum, facial pores, papules and pustules,      pictures, thus limiting this evaluation.




                                Table 2. Skin quality evaluated by digital dermoscopy.
                                                                      Out of the patients which presented with that
                                                                        finding, the percentage which showed an
 Evaluated                    Percentage of patients with that        improvement when compared to the baseline
 Characteristic                finding on baseline evaluation                  Day 21                 Day 56        Day 84
 Erythema                                     93.3%                            10.7%                   77.8%         81.5%
 Telangiectasias                              93.3%                            10.7%                   74.1%         74.1%
 Enlarged pores                               66.7%                             3.5%                   18.5%         25.9%
 Comedones                                    37.0%                             3.5%                   22.2%         25.9%




Original Article | Dermatol Pract Concept. 2023;13(3):e2023168                                                                5
    Figure 3. Polarized pictures taken with digital dermoscopy (20x magnification). Using the large telangiectasia as a reference point, it
    is possible to perceive a marked reduction in erythema and in the caliber of small vessels of the skin. The improvement was present
    on day 56 and lasted until day 84.




    Figure 4. Polarized pictures taken with digital dermoscopy (20x magnification). The rectangle highlights an improvement in tel-
    angiectasias, starting on day 56 and persisting until day 84. A global reduction in erythema also occurred at the same time period.




    Our findings are in accordance with other studies                    (dilution of 100U/ml) [6]. Our protocol combines both the
which used different treatment protocols of Abobotuli-                   standard technique and the microdosing technique, being
numtoxinA injections for the treatment of malar erythema,                able to address both the facial wrinkles and facial erythema/
including the injection of 15 to 45 units in the affected ar-            telangiectasias in the same treatment session. Our study also
eas (dilution of 100U/ml) and of 20 to 50 units per cheek                documented the evolution of these effects in facial skin, as



6                                                                             Original Article | Dermatol Pract Concept. 2023;13(3):e2023168
                                                                        upper face, as the muscles of the lower face are very sensitive
                                                                        to lower doses of the toxins and any additional dose to the
                                                                        standard treatment is able to promote side effects. Thirteen
                                                                        (43%) adverse events were short termed, as they were either
                                                                        bruises resulting from the injections or asymmetries which
                                                                        were corrected in the touch up. Nine adverse events, how-
                                                                        ever, lasted longer. They were located on the lower face and
                                                                        were all attributed to the sum of the units used in the micro-
                                                                        dosing technique over the standard technique. The adverse
                                                                        event which lasted longer was a reduction in the amplitude
                                                                        of the smile which, despite lasting more than 100 days, pro-
                                                                        gressively improved as the treatment effects wore off.
                                                                           To reduce the rate of adverse events, customized tech-
                                                                        niques with lower doses and less injection points should be
                                                                        used when applying microdoses of botulinum toxins in the
                                                                        perioral region. The total dose of microinjections and the
                                                                        number of injection sites should ideally be customized, as
                                                                        are other cosmetic treatments with botulinum toxins. In our
                                                                        study, the same doses used for each third of the face and
Figure 5. Non-polarized pictures taken with digital dermoscopy          the symmetrical injections of microdoses were a problem,
(20x magnification). A reduction in the size of the pores is seen in    especially for patients with marked facial asymmetries, as
the area with light reflections. The rectangle highlights a reduction   they require a more personalized approach to the treatment.
in the telangiectasias.
                                                                           Despite the high rate of adverse events, patient satisfac-
                                                                        tion was very high due to the efficacy of the treatment, both
                                                                        in treating facial rhytids and in improving the quality of the
the objective and subjective measurements were taken from               skin. Eighty nine percent of the patients reported that they
baseline to the final visit of the participants.                        would like to repeat the treatment if given the chance and
    Although the skin oiliness improved after the treatment             only one patient reported being dissatisfied with the results.
when assessed by the investigators using the clinical scale, no         The dissatisfaction of this patient was attributed to an ad-
significant difference was observed in the objective measure-           verse event (long-term reduction in the smile amplitude) and
ments with Sebumeter®. This finding should be interpreted               outweighed the benefits of the improvement she had in the
with caution, as our study might not have had the statistical           quality of her skin. This corroborates that perioral adverse
power to detect a significant difference and because sebum              events cause intense discomfort to patients and that the dose
production is known to vary according to different factors              applied in the perioral area should be lower than the dose
which are hard to control in spite of using a climatized set-           used in this trial (approximately 20U). Customization of the
ting, such as sweating, changes in the sleep cycle, menstrual           number and injection sites are always important in aesthetic
period and the time of the day in which the measurements                treatments.
were taken [16]. Also, the fact that the production of sebum               Our study, however, has limitations. The small sample
is not the same in different areas of the face makes it possi-          size and the non-probabilistic sample limits the interpreta-
ble that the variation in sebum production responsible for              tion of the statistical analysis, while the combined protocol
the perception of the reduced skin oiliness in the investiga-           of using the standard technique combined with the micro-
tors assessment may have happened in areas which were not               dosing technique confounds the ability to judge which tech-
objectively quantified in this study.                                   nique led to a perceived improvement in the areas which
    A total of 22 adverse events occurred in 16 (57%) of the            were treated with both techniques (glabellar, periorbital,
patients, a rate higher than what has been reported in studies          chin and forehead).
using only the standard technique [11]. These events were                  Our results suggest that the combined protocol of stan-
probably related to the sum of the effects caused by both               dard dosing and microdosing of AbobotulinumtoxinA is an
techniques: the standard aesthetic treatment, ranging from              effective treatment for facial wrinkles and for fine lines of
120U to 210U for each patient, plus the 62.5U used for mi-              the lower eyelid and perioral region, while also being able to
croinjections. Moreover, to standardize the technique, 1/3 of           improve the overall quality of the skin in the injected areas.
the total microdoses was used in each third of the face. Ide-           The therapeutic effects on erythema and the improvement
ally, the doses in the lower face should be lower than in the           of facial telangiectasias suggest that it may be a treatment



Original Article | Dermatol Pract Concept. 2023;13(3):e2023168                                                                       7
option for patients with erythematotelangiectatic rosacea.                8. Ascher B, Talarico S, Cassuto D, et al. International consen-
Given the high rate of adverse events in the perioral area                   sus recommendations on the aesthetic usage of botulinum
                                                                             toxin type A (Speywood Unit) – part I: upper facial wrinkles.
using this combined protocol, caution should be taken with
                                                                             J Eur Acad Dermatol Venereol. 2010;24(11):1278-1284. DOI:
doses and number of injection sites when injecting this area.
                                                                             10.1111/j.1468-3083.2010.03631.x. PMID: 20337830.
Customized doses and sites of injections can give optimal                 9. Steinsapir KD, Rootman D, Wulc A, Hwang C. Cosmetic Mi-
results and reduce the occurrence of adverse events.                         crodroplet Botulinum Toxin A Forehead Lift: A New Treatment
                                                                             Paradigm. Ophthalmic Plast Reconstr Surg. 2015;31(4):263-
                                                                             268. DOI: 10.1097/IOP.0000000000000282. PMID: 25216199.
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8                                                                             Original Article | Dermatol Pract Concept. 2023;13(3):e2023168
