Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis.

BACKGROUND: Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance. RESULTS: Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary. CONCLUSION: This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.

The ophthalmology microscalpel versus standard scalpels and wound healing in a rat model.

OBJECTIVE: We tested the hypothesis that the ophthalmology microscalpel, compared to standard incisional instruments, causes less trauma during incisions resulting in decreased inflammation and greater tensile strength of wounds. STUDY DESIGN: Prospective animal study. SETTING: Animal laboratory. SUBJECTS AND METHODS: Thirty-four Sprague-Dawley rats received dorsum skin incisions with the microscalpel, electrosurgical device, 11 blade scalpel, and 15 blade scalpel. Wounds were harvested at 1 week, 2 weeks, 3 weeks, and 6 weeks, then analyzed histologically in a blinded manner for inflammation markers and tested for tensile strength. RESULTS: The microscalpel wounds had significantly higher tensile strength compared to the 15 blade (P = .045) and electrocautery device (P = .000) but equivocal strength to the 11 blade (P = .457). The electrocautery wounds were weaker than all 3 steel blades. No significant difference was found between the microscalpel, 11 blade, and 15 blade incisions for the 5 markers of inflammation. Electrocautery wounds had significantly worse inflammatory scores, specifically, higher angiogenesis and larger wound gap compared to the microscalpel (P = .004, P = .002), 11 blade (P = .007, P = .023), and 15 blade (P = .010, P = .003), respectively. CONCLUSION: Microscalpel incisions result in less inflammation and increased tensile strength compared with electrocautery and higher tensile strength compared to the 15 blade in the rat model. Inflammation scores were equivocal between the microscalpel, 11 blade, and 15 blade. Our findings support the use of the microscalpel blade for facial plastic and reconstructive procedures. Prospective, randomized human studies are warranted.

The diagnosis and treatment of nasal valve collapse.

PURPOSE OF REVIEW: The nasal valve is a complex structure that can be weakened from effects of aging, surgery, and trauma. A variety of methods have been described to strengthen the nasal valve region and prevent or treat nasal obstruction, such as batten grafts, spreader grafts, butterfly grafts, flare sutures, and suspension sutures. They will be briefly discussed here, but the intent of this review is to highlight the new developments in the treatment nasal valve collapse that have appeared in the literature over the last few years. RECENT FINDINGS: Various surgical techniques and approaches for addressing nasal valve collapse have been described in the literature. Still, new techniques continue to be developed and old techniques continue to be improved upon. More specifically, minimally invasive and endoscopic approaches are being developed and improvements are made on the use of graft materials. Finally, alternatives to surgery are explored for the treatment of nasal valve collapse. SUMMARY: The aim of the new advances in the treatment of nasal valve collapse is to maximize the benefit from the surgical intervention while minimizing disruption of the normal anatomy and physiology of the nose. Another trend in the new advances explores the nonsurgical options for the treatment of nasal valve collapse.

Update on lasers in facial plastic surgery.

PURPOSE OF REVIEW: Since the theory of selective photothermolysis was described, the field of facial plastic surgery has advanced the science behind laser: tissue interactions. Particular advances in skin cooling, hair removal, intense pulsed light, and uses for aesthetic and nonaesthetic skin problems are described in this review. RECENT FINDINGS: Continued basic science research in lasers has led to improvements in current technology available to the facial plastic surgeon. Advances in skin cooling have allowed for wider use in all Fitzpatrick skin types without concomitant adverse reaction. SUMMARY: Our understanding of laser science continues to expand our knowledge in basic laser: tissue interaction. An improvement in various laser mediums and adjunctive devices provides the facial plastic surgeon with instruments to treat a wider patient population. The benefit is a successful clinical and aesthetic result with improved safety.

Surgical treatment of the inferior turbinate: new techniques.

PURPOSE OF REVIEW: Nasal obstruction causing airway resistance is often a result of structural abnormalities. Frequently, turbinate reduction procedures have been used after failure of medical management to address enlarged inferior turbinates, which potentially cause functional narrowing at the nasal valve. Controversy still exists as to the best or most appropriate method for surgical reduction of the inferior turbinate. The multitude of approaches available to the rhinologist is a testament to the lack of a single established method. RECENT FINDINGS: This paper highlights recently published literature regarding current popular and cutting-edge techniques. There is a trend toward less invasive techniques that can potentially be performed in the clinic setting, rather than in the operating room. In addition, surgical turbinate intervention demonstrates benefit in controlling symptoms of allergic rhinitis other than nasal obstruction. SUMMARY: Surgical reduction of the inferior turbinate can be performed using a variety of techniques. When analyzing different methods, emphasis on efficacy, function preservation, and avoidance of complications is paramount.