Botulinum Neurotoxin Injections Research Articles

Delineation and histological examination of the intramuscular innervation of the platysma: Application to botulinum neurotoxin injection.

This study aimed to identify the whole innervation pattern of the platysma using the Sihler's staining, and the axonal composition profile of the sensory-motor anastomosis identified by immunofluorescence assays. The findings provide a comprehensive understanding of the neural anatomy of the platysma and facilitate efficient and safe manipulation for neurotoxin injection. Ten fixed and two fresh hemifaces were included in this study. Sihler's staining was used to the study 10 fixed hemifaces and two fresh hemifaces were used for immunofluorescence assays. In all cases, the cervical branch of facial nerve (Cbr) broadly innervated the platysma, and the marginal mandibular branch of facial nerve (MMbr) provided supplementary innervation to the uppermost part of the platysma. The transverse cervical nerve (TCN), great auricular nerve (GAN), and supraclavicular nerve (SCN) were observed in the lower half of the platysma. In 30% of all cases, there was a communicating loop between the Cbr and TCN. In 20% of all the cases, a communicating branch joined between the Cbr and GAN. For successful esthetic rejuvenation procedures, a clinician should consider the Cbr distribution to the overall platysma and additionally innervation by individual nerves (MMbr, GAN, TCN, and SCN) to the middle and lower portions of the platysma muscle.

Anatomical Proposal for Botulinum Neurotoxin Injection Targeting the Platysma Muscle for Treating Platysmal Band and Jawline Lifting: A Review.

The platysma muscle is a thin superficial muscle that covers the entire neck and lower part of the face. The platysma muscle is the primary target muscle for botulinum neurotoxin injection therapy aimed at treating platysmal band and lower facial lifting. In the procedure of botulinum neurotoxin injection therapy, a lack of knowledge of the anatomy of the platysma muscle and the properties of botulinum neurotoxin can lead to side effects such as dysphagia, dysphonia, and weakness of the neck muscles. Anatomically safe injection sites have been proposed for the platysma muscle, and the appropriate injection technique has been reviewed. We proposed optimal injection sites based on the external anatomical features of the mandible. The aim of these proposal was to standardize the procedure for the effective use of botulinum neurotoxin injections by minimizing the dose unit and injection points and thereby preventing adverse events.

Neurophysiological Basis of Deep Brain Stimulation and Botulinum Neurotoxin Injection for Treating Oromandibular Dystonia.

Oromandibular dystonia (OMD) induces severe motor impairments, such as masticatory disturbances, dysphagia, and dysarthria, resulting in a serious decline in quality of life. Non-invasive brain-imaging techniques such as electroencephalography (EEG) and magnetoencephalography (MEG) are powerful approaches that can elucidate human cortical activity with high temporal resolution. Previous studies with EEG and MEG have revealed that movements in the stomatognathic system are regulated by the bilateral central cortex. Recently, in addition to the standard therapy of botulinum neurotoxin (BoNT) injection into the affected muscles, bilateral deep brain stimulation (DBS) has been applied for the treatment of OMD. However, some patients' OMD symptoms do not improve sufficiently after DBS, and they require additional BoNT therapy. In this review, we provide an overview of the unique central spatiotemporal processing mechanisms in these regions in the bilateral cortex using EEG and MEG, as they relate to the sensorimotor functions of the stomatognathic system. Increased knowledge regarding the neurophysiological underpinnings of the stomatognathic system will improve our understanding of OMD and other movement disorders, as well as aid the development of potential novel approaches such as combination treatment with BoNT injection and DBS or non-invasive cortical current stimulation therapies.

Eye Movements But Not Vision Drive the Development of Palisade Endings.

PurposeTo test whether visual experience and/or eye movements drive the postnatal development of palisade endings in extraocular muscles.MethodsIn three newborn cats, the right eye was covered until 30 days from postnatal (P) day 7 (before opening their eyes), and in three cats both eyes were covered until 45 days, also from P7. To block eye movements, another seven cats received a retrobulbar injection of botulinum neurotoxin A (BoNT-A) into the left orbit at birth and survived for 45 days (three cats) and 95 days (four cats). The distal third of the rectus muscles containing the palisade endings was used for whole-mount preparation and triple-fluorescence labeling with anti-neurofilament along with (1) anti-synaptophysin and phalloidin or (2) anti-growth associated protein 43 (GAP43) and phalloidin. Immunolabeled specimens were analyzed in the confocal laser scanning microscope.ResultsAfter unilateral and bilateral dark rearing, palisade endings were qualitatively and quantitatively equal to those from age-matched controls. After BoNT-A induced eye immobilization for 45 or 95 days, palisade endings were absent in the superior rectus and lateral rectus muscles and only present in the inferior rectus and medial rectus muscle. These BoNT-A–treated palisade endings were rudimentary and reduced in number, and the expression of the neuronal developmental protein GAP43 was significantly reduced.ConclusionsThis study demonstrates that eye immobilization, but not visual deprivation, affects palisade ending development. Palisade endings develop in the first month of life, and the present findings indicate that, during this time window, palisade endings are prone to oculomotor perturbations.

Intralesional injection of botox versus long pulsed Nd YAG laser in treatment of Acne keloidalis nuchae

Background: Acne keloidalis nuchae (AKN) is a very challenging dermatological problem for treatment depending on its chronicity and cosmetic disfiguring thus, we aim to assess the efficacy of both injection of botulinum neurotoxin A (BoNT/A) intralesionaly and long pulsed Nd:YAG laser for treatment alongside with combination of both treatment. Methods: Male patients suffering from Acne Keloidalis Nuchae divided into three groups. All patients diagnosed clinically and assessed before and after treatment with Vancouver scare scale (VSS) and global aesthetic improvement scale. Results: There were significant response for treatment of AKN with Nd:YAG laser rather than intralesional injection of BoNT/A. There was significant differences regarding global aesthetic improvement scale. Conclusion: Both long pulsed Nd YAG laser and intralesional injection of botox for treatment of Acne keloidalis nuchae may be effective.

Effectiveness of Botulinum Neurotoxin in Treatment of Scoliosis among Children and Adolescents: A Systematic Review and Meta-Analysis.

Scoliosis refers to a three-dimensional deviation in the axis of the spine. Muscle imbalance is believed to play a role in scoliosis. Botulinum neurotoxin (BoNT) can reduce muscle overactivity and may have the potential to ameliorate spinal scoliosis. This study investigated the effectiveness of intramuscular BoNT injection in vertebral curve correction and reviewed the possible influencing factors. PubMed, Medline, Cochrane Central Register of Controlled Trials, Web of Science, Airiti Library, and Index of the Taiwan Periodical Literature System databases were searched from inception until 7 September 2022 for eligible studies. The main outcome was the change in Cobb angle after BoNT application. Subgroup analysis was conducted according to differences in study designs, etiology of scoliosis, and methods used for target muscle selection. We enrolled three studies including 31 participants aged between 2 and 18 years. The meta-analysis revealed no significant reduction in the Cobb angle after BoNT injection (standardized mean difference, −0.783, 95% CI, −2.142 to 0.576). Study designs (p = 0.011) and methods used for target muscle selection (p = 0.017) but not etiology of scoliosis (p = 0.997) reached statistical significance between subgroups. In conclusion, the current meta-analysis does not support the application of BoNT in children and adolescents with scoliosis. However, a decisive conclusion could not be made due to high between-study heterogeneity and small sample size. More randomized controlled trials with appropriate target muscle selection and standard outcome measurement should be conducted to examine the efficacy of botulinum neurotoxin in treating scoliosis. INPLASY ID: INPLASY202290031.

Botulinum Neurotoxin A in the Treatment of Pharyngocutaneous Fistula after Salvage Surgery in Head and Neck Cancer Patients: Our Preliminary Results.

Objective: To analyze the effect of intraparotid injection of botulinum neurotoxin A (BoNT-A) on salivary production and the course of pharyngocutaneous fistula (PCF) in post-radiation therapy salvage surgery. Methods: A total of 13 patients who had undergone total laryngectomy or pharyngolaryngectomy were treated with BoNT-A to both parotid glands, within three days from PCF onset. The salivary flow was evaluated using a subjective rating scale as the percentage of normal function from 0% (no saliva) to 100% (normal saliva flow), before injection, every day for 2 weeks, and once a week for three months. PCFs were monitored daily. Results: Spontaneous closure of PCF occurred in 7/13 (53.84%) cases 13.6 days (range: 7–18) after treatment; 6/13 (46.16%) patients needed revision surgery. Salivary flow significantly decreased in all patients seven days after injection (from 67.2% to 36.4%; p < 0.05). Patients who had undergone either conservative or surgical treatment did not differ in salivary flow before injection, whereas the mean percentages of salivary flow calculated at each time point after injection were different (p < 0.05). Conclusions: BoNT-A contributed to the closure of the fistula in most of our cases. The subjective perception of salivary flow predicted the closure of PCF. The mean time to closure may contribute to establishing the timing of PCF surgical treatment.

Effects of Botulinum Toxin Therapy on Health-Related Quality of Life Evaluated by the Oromandibular Dystonia Rating Scale.

Oromandibular dystonia (OMD) refers to a focal dystonia in the stomatognathic system. Health-related quality of life (HRQoL) in isolated dystonia is associated with non-motor symptoms such as depression, anxiety, and pain, as well as motor symptoms. To evaluate HRQoL in patients with OMD, the therapeutic effects of botulinum neurotoxin (BoNT) therapy were assessed using a recently developed and validated comprehensive measurement tool called the Oromandibular Dystonia Rating Scale (OMDRS). Altogether, 408 patients (jaw closing dystonia, n = 223; tongue (lingual) dystonia, n = 86; jaw opening dystonia, n = 50; jaw deviation dystonia, n = 23; jaw protrusion dystonia, n = 13; and lip (labial) dystonia, n = 13) were evaluated at baseline and after the end of BoNT therapy or in a stable status. The total OMDRS score reduced significantly from 149.1 to 57.6 (p < 0.001). Mean improvement was 63.1%. All examiner-rated subscales (severity, disability, and pain) and patient-rated questionnaire scores (general, eating, speech, cosmetic, social/family life, sleep, annoyance, mood, and psychosocial function) were significantly lower at the endpoint than at baseline (p < 0.001). The BoNT injection had a highly positive impact on patient HRQoL, and the OMDRS could evaluate both motor phenomena and non-motor symptoms.

The usage of botulinum in the treatment of masticatory muscles hyperactivity

Introduction and purpose: Masticatory muscles hyperactivity is currently a very common problem among adult population. The ignorance of the symptoms and the lack or unsuccessful treatment may lead to serious health complications, which lead to major focus on improvement of the standard therapy for bruxism. The aim of the study was to provide a broad review on the promising treatment of bruxism symptoms with botulinum neurotoxin injections. Material and method: The review was conducted based on an available literature on PubMed database, searching the following phrases: bruxism, botulinum neurotoxin. Results: As bruxism has a very complex etiology, the treatment can not be narrowed down to one therapy system. Despite the fact that botulinum neurotoxin injections can not solve the primary reason of bruxism occurrence, it has shown excellent results in treatment of symptoms, since the substance has an ability to induce muscle relaxation. Therefore, such pain relief substance has shown a much better performance and long lasting results in comparison to drug therapy or behavioral treatment. Conclusions: The research confirmed that the usage of botulinum in the treatment of masticatory muscles hyperactivity is safe, well-tolerated by the patients and shows satisfying results. Conducted studies have proven that the most effective way of bruxism treatment is a therapy, which tackles both complex etiology of the disorder and its symptoms.

Comparison of Ultrasound and Electrical Stimulation Guidance for Onabotulinum Toxin-A Injections: A Randomized Crossover Study.

Botulinum neurotoxin (BoNT) injection is an established therapy for limb spasticity and focal limb dystonia. Comparative benefits of injection guidance procedures have not been rigorously studied. We compared 2 targeting techniques for onabotulinumtoxin-A (onabotA) injection for the treatment of focal hand dystonia and upper limb spasticity: electrophysiologic guidance using electrical stimulation (E-stim) and ultrasound (US). This was a 2-center, randomized, crossover, assessor-blinded trial. Participants with focal hand dystonia or upper limb spasticity, on stable onabotA therapy for at least 2 previous injection cycles, were randomly assigned to either E-stim or US with crossover at 3 months. The primary outcome was improvement in dystonia or spasticity severity on a visual analog scale (VAS; 0-100) measured 1 month after each injection. The secondary outcome was participant discomfort assessed on a VAS. Repeated-measures analysis of covariance was used with linear mixed-model covariate selection. A total of 19 participants (13 men) completed the study, 10 with upper limb spasticity and 9 with dystonia. Benefit was equivalent between the 2 techniques (VAS least-square mean [LSmean] 51.5 mm with US and 53.1 with E-stim). E-stim was perceived as more uncomfortable by participants (VAS LSmean 34.5 vs. 19.9 for E-stim and US, respectively). Procedure duration was similar with the 2 procedures. There were no serious adverse events related to either approach. US and E-Stim localization guidance techniques provide equivalent efficacy in onabotA injections for spasticity and dystonia. US guidance injections are more comfortable for participants. Both techniques are effective guidance methods, with US potentially preferable based on participant comfort.

Direct cerebello-striatal loop in dystonia as a possible new target for deep brain stimulation: A revised view of subcortical pathways involved.

Dystonia is the second most common movement disorder next to tremor, but its pathophysiology remains unsettled. Its therapeutic measures include anti-cholingerics and other medications, in addition to botulinum neurotoxin injections, and stereotaxic surgery including deep brain stimulation (DBS), but there still remain a number of patients resistant to the therapy. Evidence has been accumulating suggesting that basal ganglia in association with the cerebellum are playing a pivotal role in pathogenesis. Clinical observations such as sensory tricks and the effects of muscle afferent stimulation and blockage suggest the conflict between the cortical voluntary motor plan and the subcortical motor program or motor subroutine controlling the intended action semi-automatically. In this review, the current understanding of the possible pathways or loops involved in dystonia is presented, and we review promising new targets for Deep Brain Stimulation (DBS) including the cerebellum.

Individual Response to Botulinum Toxin Therapy in Movement Disorders: A Time Series Analysis Approach.

On a group level, satisfaction with botulinum neurotoxin (BoNT) treatment in neurological indications is high. However, it is well known that a relevant amount of patients may not respond as expected. The aim of this study is to evaluate the BoNT treatment outcome on an individual level using a statistical single-case analysis as an adjunct to traditional group statistics. The course of the daily perceived severity of symptoms across a BoNT cycle was analyzed in 20 cervical dystonia (CD) and 15 hemifacial spasm (HFS) patients. A parametric single-case autoregressive integrated moving average (ARIMA) time series analysis was used to detect individual responsiveness to BoNT treatment. Overall, both CD and HFS patients significantly responded to BoNT treatment with a gradual worsening of symptom intensities towards BoNT reinjection. However, only 8/20 CD patients (40%) and 5/15 HFS patients (33.3%) displayed the expected U-shaped curve of BoNT efficacy across a single treatment cycle. CD (but not HFS) patients who followed the expected outcome course had longer BoNT injection intervals, showed a better match to objective symptom assessments, and were characterized by a stronger certainty to control their somatic symptoms (i.e., internal medical locus of control). In addition to standard evaluation procedures, patients should be identified who do not follow the mean course-of-treatment effect. Thus, the ARIMA single-case time series analysis seems to be an appropriate addition to clinical treatment studies in order to detect individual courses of subjective symptom intensities.

Ultrasonographic analyses of Crow's feet and novel guideline for botulinum toxin injection.

Crow's feet are bilateral orbital wrinkles formed by the orbital portion of the orbicularis oculi muscle, which is the target muscle for botulinum neurotoxin (BoNT) injection. This study's aim was to demonstrate a novel BoNT injection guideline by assessing muscle width, thickness, and dynamic features using ultrasonography. Twenty healthy Korean volunteers (10 men, 10 women; mean age, 25.6) participated. The width, thickness, and dynamic movement of the orbicularis oculi muscle were measured using ultrasonography. Two volunteers were selected to receive BoNT injections. Injections were administered using a novel method with two curved reference lines passing a point 15 mm lateral to the lateral canthus (conventional injection) and a point 5 mm lateral to the lateral margin of the frontal process of zygomatic bone (additional injection). At the lateral canthus level, the distance between the lateral margin of the frontal process and the most lateral margin of the orbicularis oculi muscle was 12.5 ± 1.3 mm. The thickness of the orbicularis oculi muscle at the midpoint of the frontal process, the lateral marginal of the frontal process, and 5 mm lateral to the lateral marginal of the frontal process was 0.7 ± 0.3 mm, 1.1 ± 0.3 mm, and 1.2 ± 0.3 mm, respectively. The crow's feet of the two volunteers began to disappear from day 3 and completely disappeared on day 7 after the injection. The novel injection technique based on the ultrasonographic anatomy resulted in improvements in the appearance of crow's feet.

Use of botulinum neurotoxin in the treatment of piriformis syndrome: A systematic review

ObjectiveTo determine the pain, functional and adverse outcomes of patients with piriformis syndrome who received botulinum neurotoxin injection, and to determine the optimal dosing of botulinum neurotoxin and choices of modality used during this intervention. Literature surveySystematic review of relevant clinical studies published in English language using PubMed/Medline, Embase and CINAHL databases from October 1, 2002 to October 6, 2020. MethodologyA comprehensive search was performed to identify all studies addressing the treatment of piriformis syndrome with botulinum toxin. Two reviewers independently screened the titles, abstracts, and full texts and extracted data based on a set of predefined inclusion and exclusion criteria. 23 full-text articles were identified of which consensus was achieved for seven articles for data extraction and quality assessment. The qualities and risk of potential bias of the seven studies were appraised using the National Heart, Lung and Blood Institute (NIH) Study Quality Assessment tools for case controls, cohort studies and randomized trials. SynthesisSeven studies (n = 152 patients) were included consisting of three randomized controlled studies (RCTs), two case control studies and two cohort studies. The qualities of these studies were: Two good and one fair for the RCTs, fair for both the case controls and one good and fair for the cohort studies. Most studies reported some reduction in pain using various modalities to guide injection (CT, EMG, US or fluoroscopy). However, the included studies were heterogeneous, making it difficult to quantify pain reduction. There was minimal description of other functional outcomes. Botulinum toxin A doses range from 100 to 300U. Mild adverse effects were reported with no medical intervention needed. ConclusionsThere is fair quality of evidence to suggest botulinum toxin is safe to reduce pain in piriformis syndrome. There is insufficient data to quantify pain reduction and to describe other functional outcomes. The optimal dose of botulinum toxin A remains unclear. Modalities to guide botulinum injection into the piriformis muscle remain heterogeneous.

Novel Anatomical Proposal for Botulinum Neurotoxin Injection Targeting Lateral Canthal Rhytids.

Botulinum neurotoxin injections near the lateral canthal rhytids are commonly used in cosmetic settings; however, there is a lack of thorough anatomical knowledge, and an effective way to treat them with accumulating knowledge is needed. The anatomical characteristics concerning the injection of botulinum neurotoxin into the orbicularis oculi muscle were evaluated in this review. Current knowledge on the identification of botulinum neurotoxin injection points from recent anatomical research was assessed. The lateral canthal lines are involved with the orbicularis oculi muscle and nearby anatomical structures, and the injection points can be more precisely defined. The best possible injection sites were provided, and the injection procedure was described. This review proposes evidence for injection sites associated with the surface anatomy of the orbicularis oculi muscles to enhance the effectiveness of easing lateral canthal rhytids.

The Integration of the Hemiplegic Spastic Upper Limb Into Activities of Daily Living After Botulinum Neurotoxin Injection and Constraint-Induced Movement Therapy

The Integration of the Hemiplegic Spastic Upper Limb Into Activities of Daily Living After Botulinum Neurotoxin Injection and Constraint-Induced Movement Therapy

Comparison of Ultrasound and Electrical Stimulation Guidance for Botulinum Neurotoxin Injections: A Randomized Cross-Over Study

Comparison of Ultrasound and Electrical Stimulation Guidance for Botulinum Neurotoxin Injections: A Randomized Cross-Over Study

Short- and Long-term Central Action of Botulinum Neurotoxin Treatment in Laryngeal Dystonia.

Background and ObjectivesLaryngeal dystonia (LD) is isolated task-specific focal dystonia selectively impairing speech production. The first choice of LD treatment is botulinum neurotoxin (BoNT) injections into the affected laryngeal muscles. However, whether BoNT has a lasting therapeutic effect on disorder pathophysiology is unknown. We investigated short-term and long-term effects of BoNT treatment on brain function in patients with LD.MethodsA total of 161 participants were included in the functional MRI study. Statistical analyses examined central BoNT effects in patients with LD who were stratified based on the effectiveness and duration of treatment.ResultsPatients with LD who were treated and benefited from BoNT injections had reduced activity in the left precuneus compared with BoNT-naive and treatment nonbenefiting patients. In addition, BoNT-treated patients with adductor LD had decreased activity in the right thalamus, whereas BoNT-treated abductor patients with LD had reduced activity in the left inferior frontal cortex. No statistically significant differences in brain activity were found between patients with shorter (1–5 years) and longer (13–28 years) treatment durations. However, patients with intermediate treatment duration of 6–12 years showed reduced activity in the right cerebellum compared with patients with both shorter and longer treatment durations and reduced activity in the right prefrontal cortex compared with patients with shorter treatment duration.DiscussionOur findings suggest that the left precuneus is the site of short-term BoNT central action in patients with LD, whereas the prefrontal-cerebellar axis is engaged in the BoNT response in patients with intermediate treatment duration of 6–12 years. Involvement of these structures points to indirect action of BoNT treatment on the dystonic sensorimotor network through modulation of motor sequence planning and coordination.

Guidelines for Botulinum Neurotoxin Injection for Facial Contouring.

The hypertrophied temporalis and masseter muscles give a muscular shaped and bulky contour to the face. Botulinum neurotoxin injection methods are commonly used for facial contouring; however, adverse effects have been reported owing to a lack of delicate anatomical information. The anatomical considerations when injecting botulinum neurotoxin into the temporalis and masseter muscles were reviewed in the present study. Current knowledge on the localization of the botulinum neurotoxin injection point with more recent anatomical dissection and modified Sihler staining procedures was assessed. The authors found that, for the muscles, the injection point can be more precisely demarcated. Optimal injection sites are presented for the temporalis and masseter muscles, and the injection technique is suggested. The authors propose the optimal injection sites in relation to external anatomical landmarks for the frequently injected muscles of the face to facilitate the efficiency of botulinum neurotoxin injections. In addition, these guidelines would aid in more precise practice without the adverse effects of botulinum neurotoxin.

Evaluating intramuscular neural distribution in the cricopharyngeus muscle for injecting botulinum toxin

ObjectivesThe objective of this study was to determine the area in the cricopharyngeus muscle (CPM) where botulinum neurotoxin (BoNT) can be injected safely and effectively by evaluating neural distribution in the CPM. MethodsEleven specimens of the CPM were gathered from human cadavers. The anatomical relationship between the posterior cricoarytenoid muscle (PCAM) and the CPM was evaluated. Myelinated nerve fibers in the CPM were stained using modified Sihler's method. The CPM was classified into five zones according to the area accessible within the CPM via transcutaneous and transluminal approaches for BoNT injection as follows: i) lateral area including upper area (zone 1) and lower area (zone 2); ii) posterolateral area including upper area (zone 3) and lower area (zone 4); and iii) posterior area (zone 5). Neural distribution originating from the pharyngeal plexus and the extralaryngeal branches of recurrent laryngeal nerve (EBRLN) within each classified zone in stained specimens was determined. ResultsSix specimens (12 lateral areas, 12 posterolateral areas, and 6 posterior areas) were suitable for evaluating neural distribution within the CPM. Zone 1 was adjacent to the PCAM the most in all specimens. Nerve endings originating from the EBRLN were observed on four sides of zone 2 (33.3%, 4/12 sides) in three specimens (3/6, 50%). Neural distribution originating from the pharyngeal plexus was found on ten sides (83.3%, 10/12 sides) of zone 3 in five specimens (83.3%, 5/6 specimens) and on nine sides (75.0%, 9/12 sides) of zone 4 in five specimens (83.3%, 5/6 specimens). ConclusionThe posterolateral area (zone 3 and zone 4) is thought to be the most suitable area for alleviating the spasticity of CPM with a minimum dose of BoNT.