Chemobioresurfacing: Does Intradermal Injection of Botulinumtoxina Plus Hyaluronic Acid Improve Skin Quality?

Goals/Purpose: Chemoresurfacing describes the use of microdoses of intradermal microtoxin to improve skin quality, a concept that originated in Asia (1). A pilot study has shown combining intradermal injections of dilute microtoxin plus dilute hyaluronic acid (HA) with microneedling and topical application of exosomes has significant clinical benefit, thought to be due to pharmacologic influence rather than biostimulatory effect. To explore mechanism of action of this combination, a single-site clinical trial is underway.

Methods/Technique: Twenty patients, 20 to 70 years of age, with conditions including large pores, oily “T” zone, mild to moderate pigment irregularities, rough/dull skin appearance, and/or fine wrinkles, are to be treated with diluted incobotulinumtoxinA (INCO) plus cohesive polydensified matrix HA (CPM-HA) filler, followed by microneedling and topical exosomes.

Protocol includes single treatment of face and right postauricular region. Injectable solution is prepared by dilution of INCO with injectable saline to 30 U in 2 cc volume. 1 cc CPM-HA is mixed with 2 cc injectable saline and combined with diluted INCO. Microdoses of INCO mixture are delivered intradermally with a multi-injector device. 20 µl per 1 cm² injection point is injected through a set of nine 33-gauge needles, 0.8 mm deep; 5 cc of INCO mixture is usually sufficient to treat entire face. Radiofrequency-assisted microneedling is performed, and a thin film of topical exosome regenerative complex is applied.

Assessments include 2D and 3D photographs, Primos imaging, and linear skin roughness and computerized topographic index are compared before and after treatment. In a subset of patients, biopsy of the “control” and “treated” regions are used to assess collagen and elastin production. Assessment of treatment comfort and patient satisfaction is via a Likert scale, and clinical improvement via patient photographs evaluated by blinded reviewers.

Results/Complications: Clinical improvement is noted in reduction of pore size, pigment, and sebum production, especially in the “T” zone. Minor blemishes resolve at 3 days. Pigment and redness are reduced. Skin roughness decreases by 14-22%. Down time averages 1.5 hours; patients are able to resume normal activities within 4 hours.

Conclusion: While intradermal use of microtoxin and HA is not new, the combination with microneedling and topical biologicals is novel. Tonnard (2) noted that combining microtoxin and HA intradermally with nanofat injections, patients saw immediate benefit that lasted until the latent effect of nanofat became visible at about 3 months. The exosome effect is immediately anti-inflammatory, with long-term improvement in skin tone, texture, roughness, and intradermal thickness.

References

1. Wu, Woffles TL. Microbotox of the Lower Face and Neck: Evolution of a Personal Technique and Its Clinical Effects. Plast Reconstr Surg. 2015 Nov;136(5 Suppl):92S-100S.

2. Tonnard P. Nanofat. ISAPS Regenerative webinar, 29 May 2021.