Botulinum toxin type A (BOTOX) for treatment of migraine headaches: an open-label study.

OBJECTIVE: The object of this clinical experience was to evaluate the correlation between pericranial botulinum toxin type A (BOTOX, Allergan Corp, Irvine, CA) administration and alleviation of migraine headache symptoms. STUDY DESIGN AND SETTING: A nonrandomized, open-label study was performed at 4 different test sites. The subjects consisted of 106 patients, predominantly female, who either (1) initially sought BOTOX treatment for hyperfunctional facial lines or other dystonias with concomitant headache disorders, or (2) were candidates for BOTOX treatment specifically for headaches. Headaches were classified as true migraine, possible migraine, or nonmigraine, based on baseline headache characteristics and International Headache Society criteria. BOTOX was injected into the glabellar, temporal, frontal, and/or suboccipital regions of the head and neck. Main outcome measures were determined by severity and duration of response. The degrees of response were classified as: (1) complete (symptom elimination), (2) partial > or =50% reduction in headache frequency or severity), and (3) no response [neither (1) nor (2)]. Duration of response was measured in months for the prophylactic group. RESULTS: Among 77 true migraine subjects treated prophylactically, 51% (95% confidence interval, 39% to 62%) reported complete response with a mean (SD) response duration of 4.1 (2.6) months; 38% reported partial response with a mean (SD) response duration of 2.7 (1.2) months. Overall improvement was independent of baseline headache characteristics. Seventy percent (95% confidence interval, 35% to 93%) of 10 true migraine patients treated acutely reported complete response with improvement 1 to 2 hours after treatment. No adverse effects were reported. CONCLUSIONS: BOTOX was found to be a safe and effective therapy for both acute and prophylactic treatment of migraine headaches. Further research is needed to explore and develop the complete potential for the neuroinhibitory effects of botulinum toxin.

Histological and clinical evaluation of facial resurfacing using a carbon dioxide laser with the computer pattern generator.

OBJECTIVES: To delineate the extreme precision and uniformity of tissue ablation with a carbon dioxide laser using the computer pattern generator (CPG) (Coherent Laser Corp, Palo Alto, Calif) and to determine the ideal treatment parameters for uniform tissue ablation with minimal tissue thermal injury. Also, to evaluate postoperative healing of patients undergoing laser resurfacing compared with the traditional modalities of chemical peels and dermabrasion. DESIGN: A 3-part study was designed to demonstrate the effectiveness of this new modality. Cutaneous tissue from patients undergoing rhytidectomy was treated with a carbon dioxide laser with the CPG varying the treatment parameters. A histological analysis was completed to evaluate the uniformity of tissue ablation and thermal effect. Next, 30 tissue specimens were treated with identical power settings and evaluated histologically to determine the depth of tissue ablation, the variability in depth of ablation, and the degree of thermal effect on the underlying dermis. Finally, a prospective clinical analysis of patients undergoing facial resurfacing with the carbon dioxide laser was undertaken to determine the length of time required for reepithelialization, as well as resolution of postresurfacing erythema. PATIENTS: Seventy-four patients underwent facial resurfacing with a carbon dioxide laser with CPG. Sixty patients were treated for cosmetic procedures and 14 were treated for either chronic acne scarring or posttraumatic scarring. INTERVENTIONS: To evaluate the CPG parameters, skin specimens were treated with the same fluence while the density setting varied from 1 through 9. To evaluate tissue uniformity and thermal effect, the CPG was used with the same treatment parameters of 300 mJ and a density of 5 for all specimens. Patients undergoing clinical evaluation were treated for periorbital, perioral, or full face resurfacing. All patients were treated by the same surgeon. MAIN OUTCOME MEASURES: Histological specimens were evaluated with light microscopy and hematoxylin-eosin staining to determine the depth and uniformity of ablation and the thermal effect. Patients were followed up after the procedure and evaluated for complete reepithelialization and resolution of erythema. RESULTS: A histological evaluation revealed that a treatment parameter of 300 mJ with a density setting of 3, 4, or 5 resulted in uniform ablation of the epidermis with minimal thermal injury to the underlying dermis. At density settings of 1 and 2, irregular ablation of the tissue occurred, while at a density setting of 6 through 9, increasing degrees of thermal injury and tissue necrosis occurred. The depth of epithelial ablation with density set at 5 varied between 65 and 90 microns (average depth, 78 microns). The thermal effect in the papillary dermis varied between 0 and 45 microns (average, 28 microns). No tissue necrosis was seen. Complete reepithelialization occurred an average of 7 days following the procedure, with resolution of cutaneous erythema occurring at an average of 42 days. CONCLUSIONS: The carbon dioxide laser with the CPG is an effective modality for cutaneous exfoliation. With the proper treatment parameters, extreme accuracy and uniformity of tissue ablation can be achieved. The tissue is ablated with micrometer accuracy and minimal thermal effect to the underlying dermis. Postoperative healing is comparable to that of the traditional modalities of dermabrasion and chemical peel. Postresurfacing erythema is transient and resolved in all patients.

Subcutaneous implantation of Gore-Tex for facial reconstruction.

Subcutaneous implantation of Gore-Tex for facial reconstruction allows physicians to recontour the soft tissues of the face and to augment areas that are deficient of subcutaneous tissue for genetic, aging, and traumatic reasons. This article discusses the use of Gore-Tex in multiple implant sites and presents novel ideas for both facial and cervical augmentation.

Primary surgical management for rehabilitation of the paralyzed eye.

Protection of the eye is the primary concern in managing the patient with facial paralysis; however, the aesthetic consequences cannot be overlooked. Lagophthalmos has traditionally been treated with frequent ocular lubrication, medical eye care, and tarsorrhaphy. This approach is fraught with the difficulties of poor patient compliance and unacceptable cosmesis. We suggest a protocol for the complete ocular management with emphasis on immediate rather than delayed surgical rehabilitation as a primary therapy in facial paralysis. Gold weight implantation to the upper lid and tightening of the lower lid at the lateral canthus are simple and reliable procedures that provide immediate functional and aesthetic improvement. This surgical technique has extremely low morbidity and is reversible should facial function return. We have used this protocol in more than 30 patients with excellent results.

Malar augmentation. Patient classification and placement.

Aesthetic malar augmentation is described to improve the appearance of patients with flattening of the malar eminence, to create a more youthful appearance of the face, to make the face more oval in appearance, and to de-emphasize prominent nasal or mental profiles. Detailed preoperative analysis of surgical candidates has not been reported. Twenty models studied by photogrammetry of frontal, lateral, and oblique views were analyzed to synthesize ideal measurements of an aesthetic face with particular attention to points describing the malar mound. Photographs of patients operated on were analyzed using computer graphics to compare the synthesized ideal and surgical results. Ideal candidates are defined as those patients with ptotic malar mounds with adequate soft tissue to create a balanced and harmonious result. Examples of candidates and potential pitfalls are presented.

Congenital torticollis: evaluation by fine-needle aspiration biopsy.

Fine-needle aspiration biopsy, used extensively for evaluating head and neck masses in adults, also provides an excellent minimally invasive means of evaluating infants with neck masses and torticollis. Three cases of torticollis involving infants are presented. In each case, fine-needle aspiration revealed a benign fibrous lesion, ruling out malignancy. The remaining cytologic differential diagnosis between infantile fibromatosis, fibromatosis colli, and calcifying aponeurotic fibrosis is discussed, with mention of the possible causes of and treatment for congenital torticollis. We conclude that fine-needle aspiration provides a fast and accurate diagnosis of neck masses in infants who have congenital torticollis, thereby avoiding surgical procedures in this very young age group.