Botulinum Toxin A Administration Research Articles

Short-Term Effects of Botulinum Toxin-A Injection on the Medial Gastrocnemius Histological Features in Ambulant Children with Cerebral Palsy: A Longitudinal Pilot Study.

Botulinum toxin-A (BoNT-A) injection is known to exert beneficial effects on muscle tone, joint mobility and gait in children with cerebral palsy (CP). However, recent animal and human studies have raised the concern that BoNT-A might be harmful to muscle integrity. In CP-children, the impact of BoNT-A on muscle structure has been poorly studied, and inconsistent results have been reported. This study was aimed at determining the time course effect of a single BoNT-A administration on medial gastrocnemius (MG) morphology in CP-children. MG microbiopsies from 12 ambulant and BoNT-A-naïve CP-children (age, 3.4 (2.3) years, ranging from 2.5 to 7.8 years; seven boys and five girls; GMFCS I = 5, II = 4 and III = 3) were collected before and 3 and 6 months after BoNT-A treatment to analyze the fiber cross-sectional area (fCSA) and proportion; capillarization; and satellite cell (SC) content. Compared with the baseline, the fCSA decreased at 3 months (-14%, NS) and increased at 6 months (+13%, NS). Fiber size variability was significantly higher at 3 months (type I: +56%, p = 0.032; type IIa: +37%, p = 0.032) and 6 months (type I: +69%, p = 0.04; type IIa: +121%, p = 0.032) compared with the baseline. The higher type I proportion seen at 3 months was still present and more pronounced at 6 months (type I: +17%, p = 0.04; type IIx: -65%, p = 0.032). The capillary fiber density was reduced at 3 months (type I: -43%, NS; type II: -44%, p = 0.0320) but normalized at 6 months. There was a non-significant increase in SC/100 fibers at 3 months (+75%, NS) and 6 months (+40%, NS) compared with the baseline. These preliminary data suggest that BoNT-A induced alterations in the MG of children with CP, which were still present 6 months after BoNT-A injection but with signs of muscle recovery.

Selective Myectomies Alone vs Selective Myectomies Combined with Selective Neurectomies in Patients with Post-paretic Synkinesis - Comparing Outcomes.

In post-paretic synkinesis, muscle tone imbalance between upper and lower lip depressors and elevators, results in the inability to produce an effective smile. Surgical treatments to improve smile, focus on restoring tonicity balance between peri-oral muscles by weakening hyper-toned muscles through selective myectomies or selective neurectomies. The goal of this study was to compare objective outcomes between selective myectomies alone with those of selective myectomies combined with selective neurectomies. Retrospective cohort study performed on post-paretic synkinesis patients who underwent depressor anguli oris (DAO) myectomies or DAO and platysma myectomies with selective neurectomies. Objective outcomes included pre- and post-operative analyses of smile measures (excursion, angle, and dental show) and Botox administration (periorbital and platysmal). Thirty-seven pa tients underwent DAO myectomies only (myectomy group) and eighteen patients underwent DAO and platysma myectomies with selective neurectomies (myectomy-neurectomy group). Within group analyses showed significant angle improvement in both groups (p<.05) and improved smile excursion in the myectomy-neurectomy group (p<.05). Between group comparisons showed significant closed mouth smile excursion improvement (difference in means: -1.14 millimeters; 95% CI -2.19 to -0.09; p=.034) and significant decrease in platysmal Botox administration (difference in means: 27.36 Botox units ; 95% CI 18.72 to 36.00; p<.001) in the myectomy-neurectomy group compared to the myectomy group. This study suggests that selective myectomies and selective myectomies with selective neurectomies provide overlapping and differing benefits to peri-oral synkinesis. Selective neurectomies and platysma myectomy provided slightly improved excursion and significantly decreased botulinum injections to the platysma.

Blocking insulin-like growth factor 1 receptor signaling pathway inhibits neuromuscular junction regeneration after botulinum toxin-A treatment

Botulinum toxin-A (BTX) administration into muscle is an established treatment for conditions with excessive muscle contraction. However, botulinum therapy has short-term effectiveness, and high-dose injection of BTX could induce neutralizing antibodies against BTX. Therefore, prolonging its effects could be beneficial in a clinical situation. Insulin-like growth factor-1 receptor (IGF1R) and its ligands, insulin-like growth factor (IGF) -I and II, regulate the physiological and pathological processes of the nervous system. It has been suggested that IGF1R is involved in the process after BTX administration, but the specific regeneration mechanism remains unclear. Therefore, this study aimed to determine how inhibition of IGF1R signaling pathway affects BTX-induced muscle paralysis. The results showed that anti-IGF1R antibody administration inhibited the recovery from BTX-induced neurogenic paralysis, and the synaptic components at the neuromuscular junction (NMJ), mainly post-synaptic components, were significantly affected by the antibody. In addition, the wet weight or frequency distribution of the cross-sectional area of the muscle fibers was regulated by IGF1R, and sequential antibody administration following BTX treatment increased the number of Pax7+-satellite cells in the gastrocnemius (GC) muscle, independent of NMJ recovery. Moreover, BTX treatment upregulated mammalian target of rapamycin (mTOR)/S6 kinase signaling pathway, HDAC4, Myog, Fbxo32/MAFbx/Atrogin-1 pathway, and transcription of synaptic components, but not autophagy. Finally, IGF1R inhibition affected only mTOR/S6 kinase translational signaling in the GC muscle. In conclusion, the IGF1R signaling pathway is critical for NMJ regeneration via specific translational signals. IGF1R inhibition could be highly beneficial in clinical practice by decreasing the number of injections and total dose of BTX due to the prolonged duration of the effect.

Real-world experience of OnabotulinumtoxinA treatment in female patients with chronic migraine: a qualitative study using in-depth interviews

Background Chronic migraine (CM) causes great disability and affects an individual’s quality of life. OnabotulinumtoxinA (OBT-A, Botox®) was the first prophylactic treatment specifically indicated for CM. The aim of this study was to describe the experiences of women with CM treated with OBT-A. Materials and Methods The study design is a qualitative descriptive study. A purposeful sampling of 30 women (mean age, 42.7; standard deviation, 10.6) who had received at least two administrations of OBT-A for CM (PREEMPT protocol) was performed. Data collection included in-depth interviews and researchers’ field notes. A thematic analysis was carried out according to qualitative research guidelines. Results Five themes were identified: (a) A long way to go before Botox®, (b) First time hearing about the treatment and its expectations, (c) The administration of Botox®, (d) Treatment effects, and (e) Follow-up. Patients described a long history of treatment failures prior to the start of OBT-A treatment. Information about this migraine treatment came from the neurologist; following the information, patients had high expectations, including unrealistic expectations regarding the onset and duration of effect. They acknowledged fear of the injections and some discomfort due to the procedure. With treatment, participants reported better migraine control and an improvement in their quality of life. Follow-up had some barriers, such as delayed appointments for subsequent doses, but also strengths, such as effectiveness and few side effects. Conclusions Qualitative research offers insight into how patients with CM experience treatment with OBT-A. Our results highlight some relevant aspects that should be considered when providing OBT-A treatment.

FTP2.5 Clinical audit following initial experience from a dedicated botox clinic for the treatment of anal fissure

Abstract Background and Aims Chronic anal fissure is a common and debilitating disease. Intersphincteric injection of Botulinum Toxin A during examination under anaesthesia (EUA) is an established treatment option following failed conservative management. The aim of this study was to investigate the effectiveness of clinic-based Botox injection for treatment of chronic anal fissure as an alternative to injection under anaesthesia. Feasibility was evaluated in terms of cost, safety and sustainability. Methods This was a retrospective single centre study of prospectively collected data between August 2021 and August 2022. Demographic data, treatment protocols and follow-up outcomes at three months were collated. The relative costs were provided by the regional financial department. Results Sixty-four patients were referred to clinic in the first year. Anal fissure was confirmed in 63% of patients with 89% receiving Botox injection in the clinic setting with no major complications. Healed fissure was induced in 85% of patients reviewed at a three-month follow-up. Five patients required referral for EUA with injection of botox. An estimated cost saving of £1,308.50 per case was achieved for clinic-based Botox versus Botox administered via EUA. Clinic-based administration of Botox reduced theatre resource utilisation during the study period. Conclusion Clinic-based Botox administration is feasible, safe and effective in the treatment of chronic anal fissure. This treatment approach not only provides a clinically effective, cost-efficient alternative to surgery but reduces resource utilisation and waste which is environmentally beneficial.

Preoperative Abdominal Muscle Elongation Facilitated Laparoscopic Intraperitoneal Onlay Mesh Repair of Complex Ventral Hernia.

Background: Complex ventral hernia remains a challenging situation for any surgeon. In this study, our aim was to analyze the effect of laparoscopic intraperitoneal onlay mesh (IPOM) repair in the treatment of complex abdominal wall hernia, with the assistance of preoperative progressive pneumoperitoneum (PPP) and botulinum toxin A (BTA). Methods: In this retrospective study, we included 13 patients with complex ventral hernia between May 2021 and December 2022. All patients undergoing PPP and BTA protocol before hernia repair. The length of abdominal wall muscles and abdominal circumference were measured from CT scan. All hernias were repaired with laparoscopic or laparoscopic-assisted IPOM. Results: Thirteen patients received PPP and BTA injections. PPP and BTA administration time was over 8.8 ± 2.5 days. Before and after PPP and BTA, imaging showed that the length of lateral muscle on each side increased from 14.3 to 17.4 cm (P < .05). The abdominal circumference increased from 81.8 to 87.9 cm (P < .05). Complete fascial closure was obtained in 13 patients (100%), and no patient experienced postoperative abdominal hypertension and ventilatory support. No patient suffered from recurrent hernia to date. Conclusions: Preoperative PPP combined with BTA injection plays a role similar to component separation technique, avoids the abdominal hypertension after laparoscopic IPOM repair of complex ventral hernia.

Efficacy of Intravesical Botulinum Toxin A Injection in the Treatment of Refractory Overactive Bladder in Children.

This study aimed to evaluate the efficacy of intravesical botulinum toxin A (BoNT-A) injections for the treatment of pediatric overactive bladder (OAB) by exploring the differential treatment outcomes in children with different OAB etiologies and those who received additional intrasphincteric BoNT-A injections. We performed a retrospective review of all pediatric patients who received intravesical BoNT-A injections between January 2002 and December 2021. All patients underwent a urodynamic study at baseline and three months after BoNT-A administration. A Global Response Assessment (GRA) score of ≥2 at three months after BoNT-A injection was defined as successful treatment. Fifteen pediatric patients (median age, 11 years), including six boys and nine girls, were enrolled in the study. A statistically significant decrease in detrusor pressure from baseline to three months postoperatively was observed. Thirteen (86.7%) patients reported successful results (GRA ≥ 2). The cause of OAB and additional intrasphincteric BoNT-A injections did not affect the improvement in urodynamic parameters and treatment success. The study demonstrated that intravesical BoNT-A injection is effective and safe for the treatment of neurogenic and non-neurogenic OAB in children refractory to conventional therapies. Additionally, intrasphincteric BoNT-A injections do not provide additional benefits in the treatment of pediatric OAB.

Visual evoked potential changes following Botox administration in patients with blepharospasm.

To examine visual evoked potential (VEP) changes following botulinum toxin type A (BTA) administration in patients with blepharospasm. Patients diagnosed with blepharospasm receiving BTA administration were included in the study. Three groups, a control group and two study groups (patients examined 14days after BTA administration-Study Group 1, and patients examined 28days after BTA administration-Study Group 2) were evaluated. Dilated fundus examinations were performed following detailed ophthalmological examinations and VEP tests. Keypoint (Dantec, Denmark) and ISCEV criteria were adopted for pattern VEP (PVEP) recording. BTA was applied in the form of local injections at a total 15-30 units, at 2.5-5 units per injection. A mean 19.4 ± 3.2 units of BTA was used for each eye. N70 (ms), P100 (ms), and P100 (uV) values were statistically significantly lower in both study groups following drug administrations compared to the control group (p < 0.001 for all). Significant positive correlation was observed between increased P100 amplitudes and age in the control group (p = 0.008, r = 0.200). Significant negative correlation was observed between the BTA units used and decreased P100 amplitudes in both study groups 1 and 2 following drug administrations (p = 0.017, r = - 0.180 and p = 0.043, r = - 0.153, respectively). VEP may be an important method in the diagnosis and follow-up of blepharospasm and in determining the success of drug administration and additional therapeutic requirements.

The use of botulinum toxin in the acute management of symptomatic complex incisional hernia: a case series.

Complications of incisional hernia are amongst the commonest presentations to the emergency surgical take. Outcomes from emergency hernia repair are poor, particularly for those with complex defects and for the growing population of comorbid, high-risk patients. Attempts to avoid emergency surgery by improving success rates of non-operative management could prove hugely beneficial. Botulinum toxin A (Botox) is already used in the elective management of incisional hernia and this study evaluates if the relaxation produced could be used to augment the outcomes of conservative management of acutely presenting incisional hernia. Patients presenting between October 2020 and April 2022 without evidence of visceral ischaemia,who had been selected for a non-operative approach, were given 300 units of Botox under image guidance to the abdominal wall in addition to standard conservative measures. Twelve patients were eligible for Botox administration. Median age was 75years and median BMI was 36.45kg/m2. All patients were high risk; minimum ASA score was 3, and median frailty score was 5. In ten patients, symptoms resolved following Botox allowing for discharge without further complication. Seven subsequently referred on to the abdominal wall team. Symptoms did not settle in the two remaining patients; one required emergency laparotomy and the second was palliated. Botox may be a useful adjunct to established non-operative measures in patients with acute presentations of incisional hernia. It may improve the acute symptoms, eliminate the need for high-risk emergency surgery, or provide a bridge to abdominal wallreconstruction.

Administration of botulinum toxin a and vascular endhotelial growth factor reduce norepinephrine levels and increase viability of modified mcfarlane flap in wistar rat

Local hyperadrenergic states after a random flap elevation mediated by humoral vasoconstrictors can lead to flap necrosis. This study aimed to evaluate the effect of Botulinum Toxin A (BoNT-A) on reducing levels of Norepinephrine (NE) as the main humoral vasoactive substance, as well as its additive effect with Vascular Endothelial Growth Factor (VEGF) in increasing the viability of random flap. 28 Wistar Rats with Caudally Based Modified McFarlane Flap were divided into four groups. Group I received BoNT-A 3 days before flap elevation, group II received VEGF immediately after flap elevation, group III received a combination of BoNT-A and VEGF, group IV was a control group. Result in this study NE levels lowest was found in the BoNT-A+VEGF combination group (94.63 ± 5 .25 ng/ml, p&lt;0.05 in group I, p&lt;0.01 in groups II and IV). The highest value of FVR was shown in the BoNT-A+VEGF combination group (93.37 ± 2.19 %, p &lt; 0.05 in group I, p &lt; 0.01 in groups II and IV). Meanwhile, the increase in flap viability in the VEGF group was not statistically significant. So Conclusion administration of BoNT-A in combination with VEGF can increase the viability of random flaps by decreasing NE levels.

Hysteroscopic Botox: A Novel Pelvic Pain Treatment

<h3>Study Objective</h3> The objectives of this video are to describe the patient selection criteria, procedural steps, and postoperative care for hysteroscopic onabotulinumtoxinA (Botox) injection as a treatment for pelvic pain. <h3>Design</h3> N/A<b>.</b> This tutorial video demonstrates the surgical technique of hysteroscopic Botox administration. <h3>Setting</h3> Hysteroscopic Botox injections are administered through an operative hysteroscope introduced into the endometrial cavity. The procedure is performed in an operating room setting with the patient in dorsal lithotomy position. <h3>Patients or Participants</h3> Hysteroscopic Botox treatment can be considered in patients with pain of uterine origin who have failed conservative pelvic pain therapy, have normal pelvic imaging, and a laparoscopy negative for endometriosis. Patients ineligible for the procedure include those with an allergy to Botox or with any contraindication to hysteroscopy. Caution is warranted in patients pursuing pregnancy, as the effect of treatment on fertility is unknown. <h3>Interventions</h3> After diagnostic hysteroscopy confirms a normal endometrial cavity, a resection device is used to thin the entirety of the endometrium. 200 Units of Botox mixed with 3 mL of injectable saline is drawn into a syringe which is loaded into a control flow administration device. A hysteroscopic needle is attached to the tip of the syringe. Hysteroscopy is resumed, the needle is advanced through the operative channel, and the dilute Botox solution is injected into the myometrium at even intervals throughout the endometrial cavity. <h3>Measurements and Main Results</h3> Patient response is evaluated two weeks following the procedure using a numeric pain scale. If the patient reports significant benefit, the procedure may be repeated at six months. <h3>Conclusion</h3> Hysteroscopic Botox administration is a novel treatment approach for refractory uterine pain. One observational study demonstrates improvement in patient pain scores postoperatively. A randomized control trial is needed to confirm the efficacy of this treatment.

Botulinum Toxin A, a Better Choice for Skeletal Muscle Block in a Comparative Study With Lidocaine in Rats.

A positive response to scalene muscle block (SMB) is an important indication for the diagnosis of thoracic outlet syndrome. Lidocaine injection is commonly used in clinical practice in SMB, although there have been some cases of misdiagnosis. Botulinum toxin A (BTX-A) is one of the therapeutic agents in SMB, but whether it is also indicated for SMB diagnosis is controversial. To evaluate the muscle block efficiency of these two drugs, the contraction strength was repeatedly recorded on tibialis anterior muscle in rats. It was found that at a safe dosage, 2% lidocaine performed best at 40 μL, but it still exhibits an unsatisfactory partial blocking efficiency. Moreover, neither lidocaine injection in combination with epinephrine or dexamethasone nor multiple locations injection could improve the blocking efficiency. On the other hand, injections of 3, 6, and 12 U/kg BTX-A all showed almost complete muscle block. Gait analysis showed that antagonistic gastrocnemius muscle, responsible for heel rising, was paralyzed for nonspecific blockage in the 12 U/kg BTX-A group, but not in the 3 U/kg or 6 U/kg BTX-A group. Cleaved synaptosomal associated protein 25 (c-SNAP 25) was stained to test the transportation of BTX-A, and was additionally observed in the peripheral muscles in 6 and 12 U/kg groups. c-SNAP 25, however, was barely detectable in the spinal cord after BTX-A administration. Therefore, our results suggest that low dosage of BTX-A may be a promising option for the diagnostic SMB of thoracic outlet syndrome. SIGNIFICANCE STATEMENT: Muscle block is important for the diagnosis and treatment of thoracic outlet syndrome and commonly performed with lidocaine. However, misdiagnosis was observed sometimes. Here, we found that intramuscular injection of optimal dosage lidocaine only partially blocked the muscle contraction in rats, whereas low-dosage botulinum toxin, barely used in diagnostic block, showed almost complete block without affecting the central nervous system. This study suggests that botulinum toxin might be more suitable for muscle block than lidocaine in clinical practice.

P138. REVERSE END-TO-SIDE SPINAL ACCESSORY TO SUPRASCAPULAR SUPERCHARGE NERVE TRANSFER FOR BRACHIAL PLEXUS BIRTH INJURY

PURPOSE: We seek to describe our experience with reverse end-to-side (RETS) transfer of the spinal accessory (SAN) to the suprascapular (SSN) nerve in the reconstruction of brachial plexus birth injury (BPBI). METHODS: Retrospective review was performed from 2016-2020 to identify BPBI patients who underwent RETS transfer of SAN to SSN. Intraoperative images were reviewed, assessing proximity of SAN to SSN, as well as the relative diameter of the two nerves. Early outcomes were reviewed. RESULTS: Seven patients underwent RETS transfer of SAN to SSN. Mean age at operation was 10.8 ± 4 months. Intraoperative image review demonstrated close proximity of the distal SAN to the distal SSN in all cases. Diameter discrepancy between the SAN and SSN was recorded. RETS transfer of the SAN to the SSN was performed without tension in all 7 cases. No donor morbidity was noted in any patient. Concurrent Botox administration was performed in all cases. Average follow-up after reconstruction is 9.7 ± 10 months.All patients have demonstrated some degree of SSN functional recovery. At most recent follow up, 5 out of 7 patients demonstrate full passive ER; the two remaining are to 80 and 60 degrees. Evidence of early recovery of active external rotation has been observed in all patients. CONCLUSION: RETS transfer of the SAN to the SSN demonstrates potential to augment recovery of the SSN in the setting of neuroma-in-continuity. The technique provides an option for management of neuroma-in-continuity without a downgrade in function and without significant donor site morbidity.

Physicians' Practice of the Non-Cosmetic Uses of Botulinum Toxin: A Cross-Sectional Study in Saudi Arabia.

BackgroundAlthough botulinum toxin (BTX) has mainly been used cosmetically and therapeutically, its field of application is expanding. So far, BTX has shown promising outcomes in the management of a wide variety of medical conditions that are difficult to treat.ObjectivesWe assessed physicians’ knowledge and experience regarding the non-cosmetic use of BTX in different clinical settings.MethodsThis is a cross-sectional survey that was conducted in Riyadh, Saudi Arabia, and included physicians from different specialties, with different levels of training, and from different working hospitals. Data were collected by using a self-administered survey to assess physicians’ knowledge, experience, current practice, and specific training in relation to Botox administration for non-cosmetic use.ResultsMost participants were residents (76.19%) and specialized in internal medicine (27.62%). The majority worked in governmental hospitals (76.19%). About 73% of our sample were aware of the non-cosmetic indications of BTX, but only 44% and 55% were aware of its contraindications and adverse effects, respectively. Less than one-third (31%) of respondents administered BTX injections in their clinical practice, and about 66% of respondents had two to five years of experience giving BTX injections. The most commonly treated conditions were spastic disorders, dystonia, and then migraine. Only 4.7% and 3.6% used validated scales or instruments for planning treatment with BTX, respectively, while about 36% opted for clinical evaluation only. More experience and training in giving BTX injections significantly predicted increased awareness of adverse effects and contraindications of non-cosmetic uses. ConclusionsThe majority of specialty groups in our sample were aware of the non-cosmetic applications of botulinum toxin but did not use them to the same extent in their practice. Additionally, only a minority wished for further education on injection practices. The finding of insufficient knowledge about contraindications and the adverse effects of injections in a large number of participants, however, highlights the need for increased education, especially given the wide range of non-cosmetic applications and benefits that BTX can have for a variety of diseases.

Preoperative botulinum A toxin as an adjunct for abdominal wall reconstruction: a single-center early experience at an Academic Center in New York.

the botulinum toxin A (BTA) has been used to achieve a chemical component separation, and it has been used with favorable outcomes for the repair of complex ventral hernia (CVH) with and without loss of domain (LD). The aim of this study is to describe our early experience with the chemical component separation in the United Sates. a retrospective observational study of all patients who underwent ventral hernia repair for CVH with or without LD between July 2018 and June 2020. Preoperative BTA was injected in all patients via sonographic guidance bilaterally, between the lateral muscles to achieve chemical denervation before the operation. Patient demographics, anatomical location of the hernia, perioperative data and postoperative data are described. 36 patients underwent this technique before their hernia repair between July 2018 to June 2020. Median age was 62 years (range 30-87). Median preoperative defect size was 12cm (range 6-25) and median intraoperative defect size was 13cm (range 5-27). Median preoperative hernia sac volume (HSV) was 1338cc (128-14040), median preoperative abdominal cavity volume (ACV) was 8784cc (5197-18289) and median volume ration (HSV/ACV) was 14%. The median OR time for BTA administration was 45 minutes (range 28-495). Seroma was the most common postoperative complication in 8 of the patients (22%). Median follow up was 43 days (range 0-580). preoperative chemical component separation with BTA is a safe and effective adjunct to hernia repair in CVH repairs where a challenging midline fascial approximation is anticipated.

Botulinum toxin-induced blepharoptosis: Anatomy, etiology, prevention, and therapeutic options.

BackgroundBotulinum toxin A (BoNT‐A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate‐to‐severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT‐A which, although rare, more frequently occurs among inexperienced practitioners.ObjectivesThe purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT‐A administration including new anatomic pathways for BoNT‐A spread from the brow area to the levator palpebrae superioris muscle.MethodsA literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT‐A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations.ResultsBlepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3–14 days after injection and eventually self‐resolves after the paralytic effect of BoNT‐A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT‐A injections to the pre‐tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle.ConclusionProviders should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT‐A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into “danger zones,” which increase the risk of eyelid ptosis.

Cholinergic nerve contribution to cutaneous active vasodilation in response to exercise heat‐loading is similar to passive whole‐body heat‐loading

Introduction Twenty-five years ago, Dean Kellogg and colleagues established the sympathetic cholinergic nerve co-transmitter theory for cutaneous active vasodilation (CAVD) during passive heating in humans. In this seminal study, pretreatment of the skin with botulinum toxin type-A (BOTOX), a presynaptic cholinergic nerve blocker, abolished CAVD during passive whole-body heat stress in six subjects. To date, these findings have not been confirmed. More recently, a clear role for NO in CAVD has been established, where NO accounts for up to 50% of CAVD. The specific isoform of NO-synthase has been reported to differ between CAVD in response to different thermal loading modalities (passive heating vs. exercise). These findings suggest that there may be mechanistic differences in the skin blood flow responses (SkBF) to hyperthermic challenge that are dependent on how thermal loading is accomplished. With this in mind, it is unknown if the cholinergic co-transmitter theory of CAVD applies to other thermal loading modalities such as exercise heat-loading. Therefore, this study sought to confirm the role of cholinergic nerve activation in CAVD during passive whole-body heat-loading and expand these findings to exercise heat-loading using a cross-over study design. It was hypothesized that CAVD during exercise and passive whole-body heating would both be abolished by BOTOX administration. Methods Eight young (18-30 years) recreationally-active individuals participated in both an exercise heat-loading study day (40% VO2peak, 1 hour; seated cycle ergometer) and a passive whole-body heat-loading study day (mean skin temperature clamp @ 39°C, ~1 hour; water-perfused suit, seated), in a randomized order. Cholinergic nerve blockade was achieved through BOTOX administration ~2 weeks prior to study days. Throughout heat-loading trials, SkBF was assessed at BOTOX treated and untreated sites using laser-doppler flowmetry. Results At rest, there were no differences in SkBF expressed as % CVCmax by site (BOTOX treated vs. untreated) or by modality (Exercise heat-loading vs. passive whole body heat-loading). The SkBF response, as a function of increasing internal temperature, was similar between heat-loading modalities at BOTOX treated and untreated sites. At the end of heat-loading (@ 0.7 °C increase in internal temperature), % CVCmax at the BOTOX treated sites (Exercise: 19 ± 2 and Passive whole-body heating: 15 ± 5 % CVCmax), were significantly less (P<0.001) than at the untreated sites (Exercise: 35 ± 4 and Passive whole-body heating: 38 ± 2 % CVCmax). Additionally, there were no differences in %CVCMax between thermal loading modalities (modality, P = 0.909; modality-by-microdialysis site interaction, P=0.230) at the end of heat-loading. Conclusions We conclude that CAVD in response to exercise heat-loading and passive whole-body heat-loading are both mediated by cholinergic nerve transmission, a critical thermoregulatory mechanism whose function appears to be independent of the thermal loading modality.

Treatment of axillary bromhidrosis in adolescents by combining electrocauterization with ultrasound-guided botulinum toxin type A injection

The aim of this study is to investigate the efficacy of treatment-combined electrocauterization after removal of apocrine sweat glands with ultrasound-guided (BOTOX) injection for adolescents with axillary bromhidrosis. From January 2015 to January 2018, 90 adolescents with axillary bromhidrosis were recruited and randomly divided into three groups (group A, B, and C). Patients in group A underwent electrocauterization after removal of apocrine sweat glands, patients in group B received ultrasound-guided BOTOX injection, and patients in group C had electrocauterization after the removal of apocrine sweat glands followed by ultrasound-guided BOTOX administration after two weeks. All patients were followed up for one year. The percentages of axillary malodor score at twelve months after treatments compared with pre-operation for group A, group B, and group C were 20.2%, 27.5%, and 12.5%, respectively. Significant statistical differences were observed in changes of axillary malodor score among the three groups at three, six, nine and twelve months postoperatively. Satisfaction rates of group A, group B, and group C were 90.0%, 93.3%, and 96.7%, respectively. The side effects after surgery in group A were similar to group C, and no side effect was observed in group B. One-year postoperative scar formation rate of group A was 16.7%, which was significantly higher than that of group B (0) and group C (6.66%). Combination of electrocauterization after removal of apocrine sweat glands with ultrasound-guided BOTOX injection showed better treatment effects.

The impact of botulinum toxin type A in the treatment of drooling in children with cerebral palsy secondary to Congenital Zika Syndrome: an observational study

ABSTRACT Objective The main aim of this study was to determine the impact of botulinum toxin A (BTX-A) on severity and frequency of drooling in children with Cerebral Palsy (CP) secondary to Congenital Zika Syndrome (CZS). Methods This is a prospective longitudinal observational study including 23 children who received bilateral injections of BTX in the parotid and submandibular glands. The Thomas-Stonell & Greenberg Drooling Severity and Frequency Scale was applied by a multidisciplinary team including Speech, Language and Hearing professionals. The Global Impression of Improvement (GII) Scale was also applied to assess parents’ subjective perceptions of therapeutic response. Swallowing was assessed using Doppler ultrasonography. Univariate logistic regression was used to analyse differences between responders and non-responders. Results Participant age varied from 27 to 38 months (mean 31.78, SD = 2.61) all presented with Gross Motor Function Classification System (GMFCS) V. Drooling Severity and Frequency Scale scores ranged from 7 to 9 points (median = 9) prior to BTX administration and from 4 to 6 (median = 6) after. Pre- and post-treatment reduction in drooling severity occurred (Z = −3.746; p < 0.001). No cases of drooling worsening were reported. Only two subjects presented adverse effects attributed to BTX administration. Correlation was only confirmed with GII. Discussion This article presents the safe and positive impact of BTX-A administration guided by anatomical references described in the literature, even on children with microcephaly. Further studies are needed to facilitate the use of Doppler ultrasonography as a tool to characterize changes in sensory processing and motor response following intraoral input in children with CP.

The Role of Botulinum Toxins in Wound Management and Scar Revision

Botulinum toxin A (BoTA) has proven a safe and effective treatment across a wide variety of medical and cosmetic applications. Recently, studies have explored the use of BoTA to optimize scar formation by reducing the dynamic tension under which traumatic and surgical wounds heal via chemodenervation of underlying muscles. This article reviews advances focusing on the use of BoTA in wound management and scar revision. Several prospective randomized controlled trials provide evidence that BoTA has a positive effect on wound healing and scar formation. This effect extends beyond its chemodenervative properties to include reducing pro-fibrotic factors and minimizing fibroblast growth and differentiation to better prevent pathological scarring. Botulinum toxin is a safe and efficacious adjunct to other interventions intended to optimize scar appearance in traumatic or surgical wounds. Questions remain regarding the optimal technique, timing, and dosing for BoTA administration for ideal wound healing.