Preoperative botulinum A toxin as an adjunct for abdominal wall reconstruction: a single-center early experience at an Academic Center in New York / Toxina botulínica A pré-operatória como adjuvante na reconstrução da parede abdominal: experiência inicial em Centro Acadêmico em Nova York

ABSTRACT Introduction: 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. Methods: 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. Results: 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). Conclusion: 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.

RESUMO Introdução: a toxina botulínica A (TBA) tem sido usada para alcançar a separação química dos componentes, com resultados favoráveis para o reparo de hérnias ventrais complexas (HVC) com ou sem perda de domínio (PD). O objetivo deste estudo é descrever nossa experiência inicial com a separação química dos componentes nos Estados Unidos. Métodos: estudo retrospectivo observacional com todos os pacientes submetidos a reparo de hérnia ventral complexa com ou sem PD entre julho de 2018 e junho de 2020. A TBA pré-operatória foi injetada em todos os pacientes, guiada por ultrassonografia, bilateralmente entre os músculos laterais para alcançar a denervação química antes da operação. Dados demográficos dos pacientes, local da hérnia, dados peri-operatórios e pós-operatórios são descritos. Resultados: 36 pacientes foram submetidos a esta técnica antes do reparo da hérnia. A idade mediana foi 62 anos (30-87). O tamanho mediano pré-operatório do defeito herniário foi 12cm (6-25) e o defeito mediano intra-operatorio foi 13cm (5-27). O volume mediano do saco herniário pré-operatório foi 1.338mL (128-14.040), o volume mediano da cavidade abdominal pré-operatório foi 8.784 (5.197-18.289) mL e a razão dos volumes foi 14%. A duração mediana da operação para aplicação da TBA foi 45 minutos (28-495). O seroma foi a complicação mais comum no pós-operatório, em oito pacientes (22%). O seguimento pós-operatório mediano foi de 43 dias (0-580). Conclusão: a separação pré-operatória de componentes com TBA é tratamento adjuvante seguro e eficaz em reparos de HVC em que aproximação da fáscia é antecipadamente desafiadora.

Ocular surface status in patients with hemifacial spasm under long-lasting treatment with botulinum A toxin: A comparative fellow eye study

Purpose: The purpose of this study was to assess the effect of long-lasting botulinum A toxin injections on ocular surface parameters and to further investigate the relationship between these parameters and the duration of the treatment. Methods: In this retrospective study, patients with unilateral hemifacial spasm who were receiving botulinum A toxin injections for at least 1 year were analyzed. Healthy contralateral eyes acted as controls. The ocular surface examination included Ocular Surface Disease Index questionnaire, Schirmer test type I, tear film break-up time (TFBUT), tear osmolarity, corneal sensitivity, and corneal fluorescein staining. Results: Twenty-six patients (6 males and 20 females; mean age 76.4 ± 8.9 years) were included in the study. The mean duration of the treatment was 7.2 ± 5.4 years, and the mean frequency of injections was of one every 3.3 ± 0.4 months. TFBUT, Schirmer test, and corneal sensitivity were significantly lower in the eye homolateral to hemifacial spasm compared with the contralateral one (5.9 ± 3.2 vs 7.5 ± 4.2 s, P = 0.001; 6.2 ± 3.4 vs 9.2 ± 6.6 mm, P = 0.031; 50.8 ± 3.7 mm vs 52.3 ± 2.9 mm, P = 0.048, respectively). One month after the last injection, TFBUT further decreased from 5.9 ± 3.2 to 2.3 ± 1.2 s (P = 0.028). A significant positive correlation was found between the duration of treatment and tear osmolarity (? = 0.542, P = 0.025). Conclusion: Patients with hemifacial spasm under long-lasting treatment with serial botulinum A toxin injections showed a reduction in tear film production and stability, as well as corneal sensitivity in the treated eye compared with the contralateral one. Tear film stability further decreased 1 month after the last injection.

An observational study on glabellar wrinkle patterns in Indians

Background: Botulinum A exotoxin is an established treatment for glabellar frown lines, crow's feet, and horizontal furrows of the forehead. The glabella is probably the most common site for botulinum toxin treatment in Asians. Five glabellar contraction patterns have been classified in earlier studies based on eyebrow approximation, depression, and elevation. Unfortunately, this was found to be confusing by many practitioners. Indians, as all Asians, have smaller muscles compared to the European population, and there is no consensus on the optimal dosage per injection site or concentration of toxin to be used. Aims: (a) Identification and classification of glabellar wrinkle patterns in Indians. (b) Optimization of the minimal effective dose of toxin per site. Materials and Methods: Retrospective photographic analysis of 200 patients who received botulinum toxin for the first time to treat glabellar wrinkles was conducted. The wrinkle patterns were identified and classified by the authors based on the prevalence of perpendicular and transverse glabellar lines, nasal, and forehead wrinkles. Results: Six patterns were identified: (1) 11 (2) U (3) Pi (4) X (5) W (6) I. The relevant muscles were identified and doses optimized for those sites. Limitations: The doses mentioned in this study are not universal for all patients and toxin units would have to be altered and individualized according to the bulk of the facial muscles and individual needs. Conclusion: The investigators classification, injection patterns, and dosage may provide valuable guidance to facial esthetic treatment.

Injection of botulinum-A toxin into bulbospongiosus muscle for primary premature ejaculation: A preliminary clinical study / 中华男科学杂志

<p><b>Objective</b>To evaluate the efficacy and safety of injection of botulinum-A toxin into the bulbospongiosus muscle in the treatment of primary premature ejaculation (PPE).</p><p><b>METHODS</b>According to the inclusion criteria, we randomly assigned 70 outpatients with PPE to a trial and a control group of equal number, the former injected with 100 U botulinum-A toxin at 10 U/ml and the latter with the same volume of saline into the bulbospongiosus muscle. Then, we obtained the intravaginal ejaculatory latency time (IELT), scores of the Premature Ejaculation Profile (PEP), Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD), and Hospital Anxiety and Depression Scale (HADS), and the incidence of adverse reactions between the two groups before and 4 weeks after treatment.</p><p><b>RESULTS</b>Complete data were obtained from 69 of the patients, 34 in the trial and 35 in the control group. The effectiveness rate was 47.06% (16/34) in the former but 0 in the latter. At 4 weeks after treatment, the patients of the trial group showed a significantly longer IELT than the controls and the baseline (［2.35 ± 1.83］ vs ［0.79 ± 0.21］ and ［0.74 ±+ 0.27］ min, P < 0.01) and the controls. The patients in the trial group, in comparison with those in the saline control group and the baseline, also exhibited significant improvement in the scores of PEP-ejaculation control (1.21 ± 1.04 vs 0.49 ± 0.56 and 0.47 ± 0.51, P < 0.05), PEP-sexual satisfaction (1.32 ± 1.01 vs 0.71 ± 0.57 and 0.79 ± 0.48, P < 0.05), PEP-PE-related distress (2.12 ± 1.01 vs 2.80 ± 0.68 and 2.76 ± 1.26, P < 0.05), and PEP-PE-induced difficult relationship with the partners (1.38 ± 0.70 vs 2.37 ± 0.55 and 2.12 ± 1.49, P < 0.05). The sexual satisfaction score of the female partners after treatment was markedly improved in the trial group as compared with the control group and the baseline (1.18 ± 1.00 vs 0.57 ± 0.50 and 0.62 ± 0.60, P < 0.05). There were no statistically significant differences in MSHQ-EjD and HADS scores between the two groups before and after treatment. Adverse reactions were observed in 6 cases (17.65%) in the trial group, including 4 cases of decreased erectile hardness (11.76%) and 2 cases of incomplete urination (5.88%), which occurred from the 3 to 4 days after injection, and those with decreased erectile hardness could complete sexual intercourse without any other treatment and recovered after 3 weeks.</p><p><b>CONCLUSIONS</b>Injection of botulinum-A toxin into the bulbospongiosus muscle can be used as an option for the treatment of PPE. Its clinical application value, however, needs to be verified by further studies with larger samples.</p>

OnabotulinumtoxinA for trigeminal neuralgia: a review of the available data / Toxina Onabotulínica-A para neuralgia do trigêmeo: uma revisão dos dados disponíveis

Trigeminal neuralgia (TN) patients may develop side effects from centrally acting drugs, have contraindications for neurosurgical procedures, or experience relapse during conventional therapies. OnabotulinumtoxinA (BoNT/A) has been reported to be effective for TN, although this finding has been challenged. An overview of the available evidence based on a narrative/qualitative analysis of the literature is presented. About 90% of patients who receive BoNT/A show an improvement, a higher figure than that reported for the placebo effect of BoNT/A for other headaches. Tolerability of BoNT/A is good, and its few side-effects are transient. The articles reviewed were mainly case reports, case series and open-label trials; however, randomized controlled trials have endorsed the efficacy of BoNT/A for TN. This evidence, together with a better understanding of the analgesic mechanisms of BoNT/A and its proven efficacy in treating other pain syndromes, supports the use of this toxin as a therapeutic option for TN.

Pacientes com neuralgia do trigêmeo (NT) podem apresentar efeitos colaterais decorrentes do uso de drogas psicoativas, contra-indicações a procedimentos neurocirúrgicos ou perda da eficácia destas terapias. A neurotoxina botulínica do tipo A (NTB/A) tem demonstrado ser eficaz no alívio da NT, ainda que este achado tenha sido contestado. Uma análise narrativa/qualitativa da literatura disponível é apresentada. Cerca de 90% dos pacientes que receberam NTB/A melhoram, um número superior aos atribuíveis ao efeito placebo da NTB/A em outras cefaléias. Além disso, a NTB/A mostrou uma baixa incidência de efeitos colaterais, transitórios. Embora a maioria dos artigos consistam de relatos de caso, séries de casos e ensaios abertos, ensaios clínicos randomizados controlados recentes reafirmam a eficácia da NTB/A na NT. Estas evidências, associadas ao melhor entendimento dos mecanismos analgésicos da NTB/A e a sua eficácia em outras síndromes dolorosas, ratificam a NTB/A como uma opção terapêutica para a NT.

Botulinum Toxin Treatment on Upper Limb Function in School Age Children With Bilateral Spastic Cerebral Palsy: One Year Follow-up

OBJECTIVE: To prospectively investigate the long-term effects of botulinum toxin treatment on the upper limb function and performance of school age children with spastic bilateral cerebral palsy, who have limitations in performing activities of daily living and school activities, due to spasticity of the upper extremities. METHODS: Botulinum type A toxin (BoNT-A) was injected into 24 spastic upper limbs of 15 children. We used a Modified Ashworth Scale and a Modified Tardieu Scale for the evaluation of upper limb spasticity, and Quality of Upper Extremity Skills Test (QUEST), Canadian Occupational Performance Measure (COPM), and Test of Visual-Motor Skills-Revised (TVMS-R) for the evaluation of upper limb function and performance. RESULTS: Upper limb spasticity continuously decreased until the end of the one-year follow-up. Upper limb function on QUEST and COPM showed the best performance at 3 months and deteriorated slightly, but still showed a significantly better performance at 9 and 12 months than at pre-injection. In more functional nine subjects who could perform TVMS-R, the performance enhancement effects remained constant after 12 months, suggesting that the reduced spasticity led to the learning effect acquired by the repeated use of the affected upper limb. CONCLUSION: For school age children with bilateral spastic cerebral palsy whose upper limb functions are important, BoNT-A injections seem to be of help in the performance of school activities and activities of daily living.

CT Guided Botulinum Toxin Injection in Piriformis Syndrome

The traditional treatment of piriformis syndrome includes heat modality, deep muscle massage, slow stretch exercise, injection of local anesthetics, and surgical division of piriformis muscles in some selected cases. More recently, the use of botulinum toxin (BTX) for the treatment of piriformis syndrome has been suggested. We experienced two cases of piriformis syndrome with distinctive clinical feature. The symptoms of these two cases were not controlled by conservative managements including physical therapy, direct injection of lidocaine or steroid, or caudal block. So we injected Type A BTX in the piriformis muscle with the guidance of CT scan. 8 weeks after the botulinum injection, symptoms had almost completely disappeared, and follow up CT scan showed sufficient atrophy of piriformis muscles. The CT guided BTX injection in the piriformis muscle might emerge as a feasible technique to obtain a good local therapeutic effect without risk of imprecise inoculation.

Type A Botulinum Toxin Therapy on Thoracic Outlet Syndrome: A case report

The true neurogenic thoracic outlet syndrome (TOS), one type of the TOS, has vague and controversial clinical symptoms, so a variety of diseases can mimic the presentation of TOS, especially ulnar neuropathy or cervical root lesion. For most patients with TOS, common practice is to offer a course of conservative treatment, but its kinds are not enough and pain is too severe to do that in the chronic state. We experienced a case of true neurogenic thoracic outlet syndrome with distinctive clinical symptom and abnormal electrodiagnostic findings. The symptom was not controlled by conservative management including oral medication or physical therapy. So we injected type A botulinum toxin (Botox(R)) in the scalene and pectoralis minor muscles with ultrasonography guide. After 2 weeks, the pain decreased in visual analogue scale nine to four, and the compliance to physical therapy was improved. The result appeared to demonstrate that botulinum toxin injection may be helpful in controlling symptoms and making the patient adapt in physical therapy in the difficult case to management by any other methods.

Botulinum Toxin for Palliative Treatment of Epiphora in Patients with Nasolacrimal Duct Obstruction

PURPOSE: To describe the use of botulinum toxin injection of the lacrimal gland for palliative treatment of epiphora secondary to nasolacrimal duct obstruction. METHODS: A prospective non-comparative interventional case series study was designed to include 13 patients with nasolacrimal duct obstruction. Under topical anesthesia botulinum toxin A (1-4unit) was injected into the palpebral lobe of the lacrimal gland via a transconjunctival approach. Patients underwent a Schirmer test and a subjective evaluation of their epiphora symptoms was performed at 0 (baseline), 1, 4 and 12 weeks after injection. RESULTS: Subjective epiphora scores improved in 10 out of the 13 patients (76.9%). Schirmer test results showed objective reduction in tearing from baseline but did not strongly correlate with the subjective epiphora scores. Transient ptosis were experienced by two patients. CONCLUSIONS: Botulinum A toxin injection for palliative treatment of epiphora secondary to nasolacrimal duct obstruction is a simple, effective and safe treatment.

Morphological Changes in Extraocular Muscle of Rabbit Eye Produced by Subtenon's Botulinum A Toxin Chemodenervation

PURPOSE: Currently, when injecting botulinum a toxin into the extraocular muscle, EMG (Electromyography) is used for accurate location. In this study, we examined the effects of subtenon botulinum toxin injection without EMG guidance by quantifying the morphological changes of the extraocular muscle fibers in rabbits. METHODS: Using 10 New Zealand white rabbits, 10 units of botulinum a toxin in 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles, 5 mm from the muscle insertion in right eyes. As a control, 0.1 ml of normal saline was injected into the subtenon space of the superior rectus muscles in left eyes. At 3 weeks after injections, the bilateral superior rectus muscles of each rabbit were carefully dissected from the globe. Cross-sections of 5 micrometer thickness were obtained at the site, 5 mm from the insertion of each superior rectus muscle. Sections were stained with Masson's trichrome and observed by light microscopy. Using Image-Pro Plus software, the diameter of the orbital layer myofibers was measured and statistical analysis was done using the Kruskal-Wallis test. RESULTS: The average diameter of the orbital layer fiber cells after botulinum toxin injection was 11.5+/-2.26 micrometer at 3 weeks, whereas that of the control was 14.4+/-3.77 micrometer. The difference was statistically significant (p<0.01). CONCLUSIONS: The diameter of myofibers in the orbital layer was reduced after subtenon botulinum a toxin injection. Further studies on the duration of botulium toxin in subtenon space and the change in the size of myofibers depending on the dosage of botulinum toxin will be necessary.

Botulinum-A toxin injection into detrusor to treat detrusor hyperreflexia and neurogenic incontinence in patients with spinal cord injury / 中华泌尿外科杂志

Objective To evaluate the effects of Botulinum-A toxin (BTX-A) injection into detrusor to treat detrusor hyperreflexia and neurogenic incontinence in the patients with spinal cord injury (SCI). Methods A total of 31 patients with SCI(mean age,30 years;male 20,female 11) were included into the study.All the patients underwent urodynamic examination and voiding diary was recorded.300 U of BTX-A was dissolved in 15 ml of saline,and the solution of BTX-A was injected into 30 different points in detrusor using a flexible cystoscopic needle.The evaluation for the effects and follow-up included voiding diary,urodynamic testing and observation of adverse and toxic effects. Results After the first injection,29 of the 31 patients had symptom relief within 3 to 14 days;4 cases received the second injection;4 cases were treated in combination with anticholinergic medication;and 2 cases had no improvement and,therefore,received other treatments.The mean follow-up was 8.5 months. After 3-week treatment of BTX-A,the mean frequency of incontinence decreased from 14.2 to 2.5 times per day.The mean volume of intermittent catheterization (IC) increased from 124 to 495 ml each time.Urodynamic data showed that mean cystometric bladder storage volume increased from 133 to 475 ml,mean maximum storage detrusor pressure decreased from 62.7 to 17.1 cmH 2O(1 cmH 2O=0.098 kPa).No adverse and toxic effect was observed. Conclusions Our initial experience suggests that Botulinum-A toxin injection into detrusor to treat detrusor hyperreflexia and neurogenic incontinence in patients with SCI may be an effective,safe,feasible and micro-invasive treatment choice.However,it is necessary to observe its long term outcome.

Botulinum a toxin treatment of hemifacial spasm and blepharospasm

We studied the effects of botulinum A toxin in 101 patients with hemifacial spasm and 11 patients with blepharospasm in an open trial and double blind manner. All patients in the open trial and 6 patients in the double blind trial improved after the first injection of botulinum toxin. There was no improvement with placebo. The peak effect ranged from one to 6 days after injection and mean peak effect was 3.6 days in blepharospasm, and 4 days in hemifacial spasm. Of 144 treatments, 98.6% had excellent results, (below grade I). The duration of beneficial effect ranged 11 to 40 weeks (mean 16.5 weeks) in hemifacial spasm and 9 to 30 weeks (mean 14.2 weeks) in blepharospasm. Complications were encountered in 63.4% in hemifacial spasm and 72.7% in blepharospasm. The common side effects were dry eyes, mouth droop, ptosis and lid edema in order of frequency. These side effects were mild and resolved spontaneously in 1 to 3 weeks. Botulinum A toxin therapy is effective and convenient, and the treatment of choice for patients with hemifacial spasm and blepharospasm.

Quantitative Measurement of Neck Range of Motion in Spasmodic Torticollis Patients Treated with Botulinum A Toxin

No abstract available.

Treatment of blepharospasm with botulinum A toxin

Thirty-nine patients with blepharospasm were treated with botulinum A toxin. Twenty-six patients had essential blepharospasm, and thirteen had a hemifacial spasm. A total of 113 injections were given, and the average follow-up was 14.6 months. The mean preinjection spasm intensity was 2.9+ and the mean postinjection spasm intensity was 0.7+. The mean interval between injections was 4.4 months. The treatment was effective, although transient, in all patients with essential blepharospasm and hemifacial spasm. The toxin had a prolonged effect on the patients who had previously undergone muscle stripping procedure. The side effects were mild, transient, and local.

ELECTROPHYSIOLOGIC CHANGES AND THE THERAPEUTIC EFFECTS OF BOTULIN A ON HEMIFACIAL SPASM / 解放军医学杂志

To explore the cause and pathology of hemifacial spasm and evaluate the therapeutic efficacy of butulin A, 240 HFS patients were studied for therapeutic efficacy of multifocal facial injections with botulin A. Symptomatic alleviations after the injection were graded in comparison with the symptoms in the pre-treatment stage. Electromyography (EMG) was performed in 68 patients at random. Following the treatment, 96% of the patients were relieved of symptomes, but in 80% of the patients the symptom relapsed about one half a year later. The results showed that the latent period of EMG was longer than normal facial muscle, and the amplitude of evoked movement potential of EMG of orbiticularis occuli muscle and orbiticularis oris muscle was decreased. The cause of hemifacial spasm was resulted from pathological stimulation of the facial nerve, producing abnormal nervous conduction. The therapeutic hemifacial spasm with botulin A is an easy and effective method.