Intradermal Microdroplet Injection of Diluted Incobotulinumtoxin-A for Sebum Control, Face Lifting, and Pore Size Improvement

January 2021 | Volume 20 | Issue 1 | Original Article | 49 | Copyright © January 2021


Published online December 21, 2020

Je-Young Park MD,a* Soo Ick Cho MD, PhD,b* Keunyoung Hur MD,b Dong Hun Lee MD, PhDb

aApkoo-Jung Oracle Dermatology Center, Seoul, Republic of Korea
bDepartment of Dermatology, Seoul National University College of Medicine, Seoul, Republic of Korea

*These authors contributed equally to this work.

Because the size of facial pores is affected by sebum output,32 the effect of intradermal BTX injection on facial pores could be directly relaxing arrector pili muscles or indirectly reducing sebum production.9,13,14,33 In this study, the changes in both sebum secretion and the reduction in facial pores began from 1 week and were evident at 4 weeks. There was no tendency for sebum reduction to precede changes in facial pores. This finding suggests that INCO injection independently affects arrector pili muscles and sebaceous glands.

There have been previous studies on the improvement of facial laxity, sebum secretion, and facial pores by applying a BTX other than INCO. When BTX was used for face lifting, approximately 100 U of intradermal injection was required per session.27,29 As INCO has no unnecessary proteins and other impurities, such as inactive neurotoxin, flagellin, and clostridial DNA contaminants,17 the low antigenicity of INCO may have an advantage in procedures requiring administration of large units of BTX, such as face lifting.16,17,34

Moreover, the exact intradermal depth injection is very important in this procedure. The intradermal injection can show greater direct effects to the dermis and epidermis, and more natural results, which affect only the superficial layer of facial muscles. However, it is believed that intradermal injection of BTX might be more immunogenic than an intramuscular or subcutaneous injection because the dermis contains more dendritic cells to facilitate antigen presentation.35 Therefore, in terms of preventing immunogenesis, it might be prudent to use a highly purified BTX preparation containing only the 150 kDa neurotoxin to ensure effective, durable, and well-tolerated treatment outcomes over repeated injections.18,36

This study has some limitations. First, this study was a singlecenter retrospective study. Second, the efficacy of INCO was evaluated without a control group. However, this study demonstrated the effects of INCO on face lifting, sebum control, and facial pores up to 12 weeks after injection by using both objective and subjective scales simultaneously.

In conclusion, this is the first study, which showed that intradermal microdroplet injection with INCO could be effective for reducing sebum production, face lifting, and improvement of facial pores. The improvements persisted up to 12 weeks after a single injection.

DISCLOSURES

The authors have nothing to declare.

Funding sources: Funding and products were provided by Merz Asia Pacific Pte. Ltd.

    REFERENCES

    1. Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies. J Am Acad Dermatol. 2017;76:1027-42.
    2. Won CH, Lee HM, Lee WS, et al. Efficacy and safety of a novel botulinum toxin type A product for the treatment of moderate to severe glabellar lines: a randomized, double-blind, active-controlled multicenter study. Dermatol Surg. 2013;39:171-8.
    3. Lee DH, Kang SM, Feneran A, et al. RimabotulinumtoxinB vs. onabotulinumtoxinA for the treatment of forehead lines: an evaluator-blind, randomized, pilot study. J Eur Acad Dermatol Venereol. 2013;27:e1-7.
    4. Lee DH, Jin SP, Cho S, et al. RimabotulinumtoxinB versus OnabotulinumtoxinA in the treatment of masseter hypertrophy: a 24-week double-blind randomized split-face study. Dermatology. 2013;226:227-32.
    5. Ahn BK, Kim YS, Kim HJ, et al. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39:1843-60.
    6. Adilson D. Minimally Invasive Aesthetic Procedures. Berlin: Springer; 2020.
    7. Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents. J Am Acad Dermatol. 2017;76:1013-24.
    8. Wanitphakdeedecha R, Ungaksornpairote C, Kaewkes A, et al. The comparison between intradermal injection of abobotulinumtoxinA and normal saline for face-lifting: a split-face randomized controlled trial. J Cosmet Dermatol. 2016;15:452-57.
    9. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore size. J Drugs Dermatol. 2008;7:847-50.
    10. Sayed KS, Hegazy R, Gawdat HI, et al. The efficacy of intradermal injections of botulinum toxin in the management of enlarged facial pores and seborrhea: a split face-controlled study. J Dermatolog Treat. 2020:1-7.
    11. Min P, Xi W, Grassetti L, et al. Sebum production alteration after botulinum toxin type a injections for the treatment of forehead rhytides: a prospective randomized double-blind dose-comparative clinical investigation. Aesthet Surg J. 2015;35:600-10.
    12. Rose AE, Goldberg DJ. Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin. Dermatol Surg. 2013;39:443-8.
    13. Shuo L, Ting Y, KeLun W, et al. Efficacy and possible mechanisms of botulinum toxin treatment of oily skin. J Cosmet Dermatol. 2019;18:451-57.
    14. Li ZJ, Park SB, Sohn KC, et al. Regulation of lipid production by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013;72:116-22.
    15. Sapra P, Demay S, Sapra S, et al. A single-blind, split-face, randomized, pilot study comparing the effects of intradermal and intramuscular injection of two commercially available botulinum toxin a formulas to reduce signs of facial aging. J Clin Aesthet Dermatol. 2017;10:34-44.
    16. Kerscher M, Wanitphakdeedecha R, Trindade de Almeida A, et al. IncobotulinumtoxinA: a highly purified and precisely manufactured botulinum neurotoxin type A. J Drugs Dermatol. 2019;18:52-57.
    17. Park JY, Sunga O, Wanitphakdeedecha R, et al. Neurotoxin impurities: a review of threats to efficacy. Plast Reconstr Surg Glob Open. 2020;8:e2627.
    18. Dressler D. Five-year experience with incobotulinumtoxinA (Xeomin((R)) ): the first botulinum toxin drug free of complexing proteins. Eur J Neurol. 2012;19:385-9.
    19. Steinsapir KD, Rootman D, Wulc A, et al. Cosmetic microdroplet botulinum toxin a forehead lift: a new treatment paradigm. Ophthalmic Plast Reconstr Surg. 2015;31:263-8.
    20. Imhof M, Kuhne U. Introduction of the microdroplet technique with incobotulinumtoxin a for the treatment of crow's feet. J Clin Aesthet Dermatol. 2013;6:40-4.
    21. Youn SW, Park ES, Lee DH, et al. Does facial sebum excretion really affect the development of acne? Brit J Dermatol. 2005;153:919-24.
    22. Pierard GE, Pierard-Franchimont C, Marks R, et al. EEMCO guidance for the in vivo assessment of skin greasiness. The EEMCO Group. Skin Pharmacol Appl Skin Physiol. 2000;13:372-89.
    23. Choi JW, Suh YC, Song SY, et al. 3D photogrammetric analysis of the nasal tip projection and derotation based on the nasal tip quadripod concept. Aesthetic Plast Surg. 2017;41:608-17.
    24. Kim SC, Kim HB, Jeong WS, et al. Comparison of facial proportions between beauty pageant contestants and ordinary young women of korean ethnicity: a three-dimensional photogrammetric analysis. Aesthet Plast Surg. 2018;42:748-58.
    25. Kim YK, Moon SW, Yun PY, et al. evaluation of soft tissue changes around the lips after mandibular setback surgery with minimal orthodontics using threedimensional stereophotogrammetry. J Oral Maxillofac Surg. 2016;74:1044- 54.
    26. Leal Silva HG. Facial Laxity Rating Scale Validation Study. Dermatol Surg. 2016;42:1370-79.
    27. Petchngaovilai C. Midface lifting with botulinum toxin: intradermal technique. J Cosmet Dermatol. 2009;8:312-6.
    28. Chang SP, Tsai HH, Chen WY, et al. The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A. Int J Dermatol. 2008;47:1287-94.
    29. Sirithanabadeekul P, Lapsomboonsiri S, Rungjang A, et al. Split face comparison between common concentration vs double dilution of intradermal abobotulinum toxin type A (Dysport) injection for facial lifting in Asians. J Cosmet Dermatol. 2018;17:355-60.
    30. Rzany B, Dill-Muller D, Grablowitz D, et al. Repeated botulinum toxin A injections for the treatment of lines in the upper face: a retrospective study of 4,103 treatments in 945 patients. Dermatol Surg. 2007;33:S18-25.
    31. Zouboulis CC, Baron JM, Bohm M, et al. Frontiers in sebaceous gland biology and pathology. Exp Dermatol. 2008;17:542-51.
    32. Roh M, Han M, Kim D, et al. Sebum output as a factor contributing to the size of facial pores. Brit J Dermatol. 2006;155:890-94.
    33. Lee SK. Multiple intradermal small bolus injection of botulinum toxin: The limit and the potentiality. J Cosmet Laser Ther. 2012;14:304-06.
    34. Hefter H, Hartmann C, Kahlen U, et al. Prospective analysis of neutralising antibody titres in secondary non-responders under continuous treatment with a botulinumtoxin type A preparation free of complexing proteins--a single cohort 4-year follow-up study. BMJ Open. 2012;2.
    35. Zhang L, Wang W, Wang S. Effect of vaccine administration modality on immunogenicity and efficacy. Expert Rev Vaccines. 2015;14:1509-23.
    36. Park JY, Sung NK, Pitt JM. Efficacy and tolerability of incobotulinumtoxina for treating glabellar frown lines in Korean Adults: A Postmarketing Observational Study. Dermatol Surg. 2017.

    AUTHOR CORRESPONDENCE

    Dong Hun Lee MD PhD ivymed27@snu.ac.kr
    Close Menu