Iatrogenic Blepharoptosis: Multimodal Management and Treatment Technique With Botulinum Toxin Type A

Context: Acne is a common skin condition characterized by chronic inflammation of the pilosebaceous unit. Increased sebum production is a key component of acne pathogenesis. Various therapies are available for acne, including topical, systemic, and physical treatments. Botulinum toxin is increasingly used in facial cosmetic procedures. Observations suggest that botulinum toxin type A (BoNT-A) may reduce sebum levels in the face. This finding could potentially lead to the development of a new treatment for oily skin and acne. Evidence Acquisition: A retrospective literature review was conducted by searching the PubMed, Web of Science, EMBASE, and SCOPUS databases using keywords such as "acne," "acne treatment," "oily skin," and "botulinum toxin type A." The review focused on studies that assessed the impact of BoNT-A on patients with acne vulgaris and oily skin, as well as studies that measured skin sebum levels and pore size following BoNT-A application. Results: Nine studies were reviewed. Of these, two evaluated the effects of BoNT-A on 30 and 35 patients with acne vulgaris. Four studies assessed sebum reduction in 20, 50, 42, and 20 patients. Three studies evaluated both sebum reduction and pore size tightening in 10, 25, and 20 patients. Eight studies demonstrated that the application of BoNT-A has a positive effect on patients with acne and reduces sebum production in facial skin. Only one study, which evaluated both sebum reduction and pore size tightening, found no significant effect. Overall, the studies indicate that BoNT-A application can positively impact acne and reduce facial sebum production. Specifically, intradermal application of BoNT-A at low dosages can help reduce acne, sebum production, and tighten pores. Conclusions: BoNT-A shows promise as a treatment for acne and oily skin. While cost-effectiveness may be a challenge for some patients, the benefits of BoNT-A make it a treatment option worth considering. With further studies to optimize dosages and determine the longest duration of efficacy, BoNT-A has the potential to revolutionize the treatment of acne and oily skin.

This study aims to assess the influence of the cosmetic use of Botulinum toxin type A (BTX-A) on temperature measurements using Infrared thermography (IT). A quantitative cross-sectional study was conducted with 16 patients to examine the cosmetic application of BTX-A in the upper third of the face to treat dynamic wrinkles (expression lines). The substance used in the patients was Botulinum Toxin type A DYSPORT® 500IU. A thermogram in frontal norm was acquired from each patient in three different moments: (M1) before BTX-A application, (M2) 10min after BTX-A application, and (M3) five days after BTX-A application. The ROIs were demarcated in each image with a diameter of 10mm, and then the average temperature values of each ROI were recorded. Mixed ANOVA, with Tukey's post hoc test, was used to determine interactions between factors in the dependent variable. The paired T-test was used to assess whether the mean temperatures on the face's right and left sides were statistically different. The significance level was set at 5%, considering p < 0.05. For the left-side temporal ROI, statistically significant differences were observed only between the different assessed times (p = 0.010). Considering the mean temperature difference, at the temporal ROI, a reduction of the M2 temperature was observed (ΔT = 0.3℃) and an increase at M3 (ΔT = 0.6℃). The cosmetic use of BTX-A may alter skin temperature values assessed using IT, and this effect can last for days.

Post-stroke spasticity (PSS) is effectively treated with intramuscular botulinum toxin type A (BoNT-A), although the clinical improvement is likely mediated by changes at the central nervous system level. Using functional magnetic resonance imaging (fMRI) of the brain, this study aims to confirm and locate BoNT-A-related changes during motor imagery with the impaired hand in severe PSS. Temporary alterations in primary and secondary sensorimotor representation of the impaired upper limb were expected. Thirty chronic stroke patients with upper limb PSS undergoing comprehensive treatment including physiotherapy and indicated for BoNT treatment were investigated. A change in PSS of the upper limb was assessed with the modified Ashworth scale (MAS). fMRI and clinical assessments were performed before (W0) and 4 weeks (W4) and 11 weeks (W11) after BoNT-A application. fMRI data were acquired using 1.5-Tesla scanners during imagery of finger-thumb opposition sequences with the impaired hand. At the group level, we separately modeled (1) average activation at each time point with the MAS score and age at W0 as covariates; and (2) within-subject effect of BoNT-A and the effect of time since W0 as independent variables. Comprehensive treatment of PSS with BoNT-A significantly decreased PSS of the upper limb with a maximal effect at W4. Task-related fMRI prior to treatment (W0) showed extensive activation of bilateral frontoparietal sensorimotor cortical areas, bilateral cerebellum, and contralesional basal ganglia and thalamus. After BoNT-A application (W4), the activation extent decreased globally, mostly in the bilateral parietal cortices and cerebellum, but returned close to baseline at W11. The intra-subject contrast revealed a significant BoNT-A effect, manifesting as a transient decrease in the activation of the ipsilesional intraparietal sulcus and superior parietal lobule. We demonstrate that BoNT-A treatment of PSS of the upper limb is associated with transient changes in the ipsilesional posterior parietal cortex, possibly resulting from temporarily altered sensorimotor upper limb representations.

28. Modulation of cerebral sensorimotor circuits during botulinum toxin treatment of cervical dystonia

Abdominal wall hernia secondary to open abdomen management represents a surgical challenge. The hernia worsens due to lateral muscle retraction. Our objective was to evaluate if Botulinum Toxin Type A (BTA) application in lateral abdominal wall muscles modifies its thickness and length. A clinical trial of male trauma patients with hernia secondary to open abdomen management was performed from January 2009 to July 2011. Thickness and length of lateral abdominal muscles were measured by a basal Computed Tomography and 1 month after BTA application. A dosage of 250 units of BTA was applied at five points at each side between the external and internal oblique muscles under ultrasonographic guidance. Statistical analysis for differences between basal and after BTA application measures was performed by a paired Student's t test (significance: p<0.05). Seventeen male patients with a mean age of 35years were included. There were muscle measure modifications in all the patients. Left muscle thickness: mean reduction of 1±0.55cm (p<0.001). Right muscle thickness: mean reduction of 1.00±0.49cm (p<0.001). Left muscle length: mean increase of 2.44±1.22cm (p<0.001). Right muscle length: mean increase of 2.59±1.38cm (p<0.001). No complications secondary to BTA or recurrences at mean follow-up of 49months were observed. BTA application in lateral abdominal muscles decreases its thickness and increases its length in abdominal wall hernia patients secondary to open abdomen management.

Therapeutic effects of botulinum toxin type A in subjects with gummy smile: A longitudinal sEMG approach

Knee flexion contracture (KFC) remains a common complication of haemoarthrosis in children and young adults with haemophilia. If the KFC is not treated properly it produces disability, postural and gait abnormalities. Evaluate the effectiveness of conservative treatment of KFC with Botulinum toxin type A (BTX-A) in PWH. Seventeen patients were treated, with 21 affected knees. Mean age was 26 years. The mean follow up was 12 months. We evaluated flexion and KFC pretreatment BTX-A and up to 12 months posttreatment. BTX-A application was in hamstring and calf muscles. To evaluate the function, a questionnaire about different activities was made, and it was checked 3, 6 and 12 months after BTX-A. According to the degree of KFC, knees were divided into 3 groups: Group 1: -10° to -30° (n = 10), Group 2: -31° to -45° (n = 6) Group 3: -46° or more (n = 5). The average KFC improved from -38° to -24°. The improvement was 14° (P < 0.001). The average KFC improvement was 9° in group 1, 17° in group 2, and 23° in group 3. There was a high correlation between the improvement in KFC and the total score of the questionnaire R = 0.77. Treatment of KFC with BTX-A improves knee-related functional activities, with the advantage of being a low-cost procedure and easy to apply.

Botulinum toxin type A (BTA) is an adjuvant tool used in the preoperative optimization of complex hernias before abdominal wall reconstruction (AWR). This study aims to investigate changes in the abdominal cavity and hernia sac dimensions after BTA application. A prospective study with 27 patients with a hernia defect of ≥ 10cm and loss of domain (LOD) ≥ 20% underwent AWR. Computed tomography (CT) measurements and volumetry before and after the application of BTA were performed. Intraoperative and postoperative outcomes were evaluated. Imaging post-BTA revealed hernia width reduction of 1.9cm (p = 0.002), lateral abdominal wall muscle elongation of 3.1cm (p < 0.001), hernia volume reduction (HV) from 2.9 ± 0.9L to 2.4 ± 0.8L (p < 0.001), increase in abdominal cavity volume (ACV) from 9.7 ± 2.5L to 10.3L ± 2.4L (p = 0.003), and a reduction in the HV/ACV ratio from 30.2 ± 5% to 23.4 ± 6% (p < 0.001). Fascial closure was achieved in 92.6% of cases and component separation was required in 78%. The average variation in pulmonary plateau pressure was 3.53 cmH2O, and there were no postoperative respiratory failure recorded. At the 90-day follow-up, the wound morbidity rate was 25%, unplanned readmissions were 11%, and hernia recurrence 7.4%. BTA produces measurable volumetric changes in abdominal wall and appears to facilitate fascial closure. Further studies are required to determine the role of BTA in the surgical armamentarium for complex hernia repair.

Autologous fat grafting is a widely used technique in plastic and reconstructive surgery for soft tissue augmentation. Despite its advantages, the primary limitation is the unpredictable retention rate of transplanted fat. Recent studies suggest that botulinum toxin type A (BTX-A) can enhance fat graft survival by promoting angiogenesis and muscle paralysis. This review explores the potential of BTX-A as an adjuvant in autologous fat grafting, providing insights into its mechanisms, benefits, and the need for further clinical validation. A literature review was conducted using PubMed, Web of Science, MEDLINE, and Embase. Keywords related to BTX-A, fat grafting, fat graft survival, and angiogenesis were used. Comparative studies reporting histological changes following BTX-A application in fat grafting were included. Exclusion criteria involved case reports with fewer than three animals, reviews, and letters. The initial search yielded 108 articles, with seven experimental studies meeting the criteria. These studies demonstrated that BTX-A enhances fat graft retention by promoting vascularization and adipose-derived stem cell differentiation. However, these results are mainly based on small animal models. While BTX-A shows promise in improving autologous fat grafting outcomes, its efficacy and safety in humans need validation through large-scale clinical trials. Translating these preclinical findings into human trials is crucial to establish standardized protocols and optimize clinical outcomes. Future research should focus on optimizing dosage and injection sites, conducting long-term follow-up studies, and performing multicenter trials to verify the findings.

Abdominal wall hernia repair after open abdomen management represents a surgical challenge, particularly due to muscle tension and lateral retraction. This study was designed to propose the use of Botulinum Toxin Type A (BTA) before abdominal wall hernia repair. A prospective study of patients with abdominal wall hernia after open abdomen management was undertaken between September 2007 and January 2009. Bilateral BTA application was performed under electromyographic guidance at the abdominal wall. Transverse abdominal wall defect measurement was practiced at weekly intervals: clinically, in the first two patients, and with CT scan in the following 10 patients. Surgical closure was scheduled if no further hernia defect reduction was noted. Patients were followed at monthly hospital visits. In the first two patients, a hernia defect reduction of 50 and 47.2%, respectively, was documented by the third week after BTA application, with no further reduction. In the 10 patients under CT scan hernia defect measurement, when comparing the initial mean transverse defect measure and at 4 weeks after BTA application (13.85 +/- 1.49 cm vs. 8.6 +/- 2.07 cm), an overall mean reduction of 5.25 +/- 2.32 cm was observed (p < 0.001; 95% confidence interval, 3.59-6.91). Hernia repair was performed, with no recurrences at a mean follow-up of 9.08 months. BTA application before abdominal wall hernia repair seems to be useful. The lateral muscles paralysis achieved and transverse hernia defect reduction allows a minimal tension closure. To our knowledge, this is the first report of BTA application before abdominal wall hernia reconstruction.

We evaluated the effects of botulinum toxin type A (BTA) - abobotulinumtoxinA on passive motion resistance (PMR) values of lower limbs affected muscles and on the functional motor status in children with spastic cerebral palsy (CP). In Group I (28 lower limbs with spastic muscles), and in Group II (14 lower limbs with dynamic spastic equinus) BTA was administered. Physical therapy was prescribed for 16 weeks. We estimated PMR using the Modified Ashworth Scale. Achieved functional motor level was evaluated by Gross Motor Function Classification System (GMFCS) and Gross Motor Function Measure (GMFM). Parameters were assessed before treatment and after 3,8,16 weeks and 6 months respectively. In Group I, PMR was significantly lower for hip adductors and knee extensors over 3-16 weeks, and for ankle joint extensors in both groups. There were significant differences for both groups in frequencies of GMFCS values after 16 weeks from BTA application. There was a significant increase in GMFM scores after 8 and 16 weeks from BTA application in both groups of patients. BTA treatment in CP children is followed by reduction in PMR values and improvement in functional motor status.

Facial rhytides represent a widespread aesthetic concern. In particular, glabellar lines are perceived as a sign of aging and may give an erroneous impression of negative emotions. The onset of glabellar lines is closely related to the movements of the underlying muscles. Botulinum toxins inhibit the release of acetylcholine into the synaptic cleft and therefore result in temporary muscle paralysis. The observation that botulinum toxin (BTX) smoothed facial lines when used therapeutically led researchers to study the toxin effect on glabellar lines. Nowadays, the use of BTX to smooth glabellar frown lines represents the leading procedure in aesthetic facial treatments and an increasing number of BTX formulations are becoming available. This article provides a comparative evaluation of currently available BTX options for the treatment of glabellar lines. Toxins have been divided into three groups, based on whether they have obtained approval for cosmetic use (approved treatments) or not (off-label treatments), or whether they are still under investigation (experimental treatments). We examine the basic similarities and differences between available botulinum toxins, and summarize the pharmacokinetics and dosing. All approved treatments consist of BTX type A (BTX-A) and differ in their molecular weight, as some formulations are made of a BTX-A complex of 900 kDa while the latest option on the market is a 150 kDa BTX-A that is free from complexing proteins. As for the dosage, the important aspect that emerges from this comparison is that even within a given serotype, such as BTX-A, formulations are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes. There is a substantial body of published evidence on the use of these approved treatments for facial enhancement, proving efficacy and safety. We investigate the methods of evaluation used for each toxin and review the safety and efficacy data reported in the literature. Minor adverse effects, such as headache, blepharoptosis, and injection-site reactions, are relatively frequent but transient, whilst major adverse effects are rare. Some botulinum toxins, i.e. BTX type B, that are approved for therapeutic applications are used off-label for cosmetic indications, thus without the approval of the health regulatory committees and without sufficient published evidence on safety and efficacy. As for experimental treatments, a number of BTX products are currently in development or have been recently launched for aesthetic applications. These products have been specifically designed to overcome some of the limitations present in the older generation of products. However, some of these toxins may be easily purchased via the Internet, without having any license or approval for cosmetic or therapeutic indications; these products must be considered unsafe and are potentially a severe health risk for patients.

Effect of Botulinum Toxin Type A on Mandibular Fracture Healing: An Experimental Study in Rabbits

O distúrbio de maior frequencia das desordens do neurônio motor superior é a espasticidade, caracterizada por uma hiperexcitabilidade dos reflexos miotáticos e cutâneos que fomentam o tônus muscular (hipertonia espástica). O propósito deste estudo foi fazer um levantamento literário analisando os aspectos neurofisiológicos e musculares possivelmente envolvidos na espasticidade e como a Toxina Botulínica do tipo A (TBA) age no controle e redução da espasticidade. Os resultados encontrados na literatura demonstram claramente melhora no tônus muscular de pacientes submetidos ao uso da TBA. Os testes que combinam a TBA e Fisioterapia, prevaleceram aos grupos de controle que foram somente submetidos à Fisioterapia ou a aplicação de TBA isolados. Ademais, estudos recentes sugerem a presença da TBA em circuitos do sistema nervoso central, provavelmente conduzida via fluxo axoplasmático retrogrado e transcitose. Os mecanismos envolvidos na espasticidade são ainda pouco compreendidos e os efeitos da TBA a longo prazo em humanos ainda não são bem conhecidos. Por este motivo, novas pesquisas deverão ser realizadas a fim de verificar a viabilidade e segurança de tratamentos empregando esta substância de efeito letal em seres humanos.

Objective To evaluate the safety and efficacy of botulinum toxin type A for injection in the treatment of post-stroke upper limb spasticity (dosage was 200 U, or 240 U if combined with thumb spasticity). Methods The study was a multi-center, stratified block randomized, double-blind, placebo-controlled trial. All the qualified subjects were from 15 clinical centers from September 2014 to February 2016. They were randomized (2∶1) to injections of botulinum toxin type A made in China (200-240 U; n=118) or placebo (n=60) in pivotal phase after informed consent signed. The study was divided into two stages. The pivotal trial phase included a one-week screening, 12-week double-blind treatment, followed by an expanded phase which included six-week open-label treatment. The tone of the wrist, finger, thumb flexors was assessed at baseline and at weeks 0, 1, 4, 6, 8, 12, 16 and 18 using Modified Ashworth Scale (MAS), disability in activities of daily living was rated using the Disability Assessment Scale and impaction on pain, muscle tone and deformity was assessed using the Global Assessment Scale. The primary endpoint was the score difference between botulinum toxin type A and placebo groups in the tone of the wrist flexor using MAS at six weeks compared to baseline. Results Muscle tone MAS score in the wrist flexor of botulinum toxin type A and placebo groups at six weeks changed -1.00(-2.00, -1.00) and 0.00(-0.50, 0.00) respectively from baseline. Botulinum toxin type A was significantly superior to placebo for the primary endpoint (Z=6.618, P<0.01). The safety measurement showed 10 subjects who received botulinum toxin type A had 13 adverse reactions, with an incidence of 8.47% (10/118), and three subjects who received placebo had three adverse reactions, with an incidence of 5.00% (3/60) during the pivotal trial phase. All adverse reactions were mild to moderate, none serious. There was no significant difference in adverse reactions incidence between the botulinum toxin type A and the placebo groups. During the expanded phase three subjects had four adverse reactions and the incidence was 1.95%. All adverse reactions were mild, none serious. Conclusion Botulinum toxin type A was found to be safe and efficacious for the treatment of post-stroke upper limb spasticity. Clinical Trial Registration: China Drug Trials, CTR20131191 Key words: Stroke; Upper extremity; Spasm; Botulinum toxins, type A