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Abstract and Figures
Botulinum toxin has been utilised successfully in many facial and extra facial regions to limit superfluous movement. Scars, whether traumatic or disease-related, are treated with many modalities.
To assess the available literature concerning the prophylactic use of botulinum toxin for the improvement in the cosmetic outcome of scars induced by surgery and to examine its role in the treatment of established scars alone, as also combined with other modalities.
The results of the prophylactic use of botulinum toxin to limit the resultant scarring from surgery are examined by a literature review. The primary and adjunctive use of botulinum toxin in the treatment of post acne and post surgical and traumatic scars is explored by case examples.
Literature review and personal experience shows good Improvement in the appearance of scars with the use of botulinum toxin alone or with other adjuvant modalities in the treatment of scars.
Botulinum toxin would appear to be useful both in the prophylaxis and treatment of certain types of scars.
To read the full-text of this research, you can request a copy directly from the author.
... Although excision techniques such as Z or W plasty are useful in reorientation of scar direction, they are not always completely effective alternatives and may create elongation of the scar. 5 Such surgical techniques, when carefully executed, reduce rather than eliminate the muscle tension that acts on the healing wound. Repeated micro trauma caused by the continuous displacement of injured tissue induces a prolonged inflammatory response and an increased metabolic activity during healing. ...
... Multiple constellation of factors, such as a combination of cytokines (TGF-B1, Interleukin-6, Interleukin-8), act dimensionally in inducing the differentiation of dermal fibroblasts to myofibroblasts. 5 This further might lead to excessive synthesis of fibrotic extracellular matrix, perturbed matrix homeostasis, contraction, and diminished matrix metalloproteases synthesis, which is significantly involved in signaling pathways in in vitro scar formation, leading to hypertrophic and pigmented scars sometimes. ...
... Scar revision procedures also assist restore the function, by reducing skin and soft-tissue contractures. 5,10 In a series of articles, researchers at the Mayo Clinic initially showed favorable results in a randomized, double-blinded, placebo-controlled study for scars, in which the halves of foreheads that were injected with Botuli- Fig. 2. Showing after image of patient 1, on whom scar revision surgery was performed for the facial scar caused due to burns. results after 8 sessions of FCO 2 laser. ...
Background:. Wounds of the face are known to heal poorly with conspicuous scarring. Hence, it is crucial to address the distracting effect of muscle pull on immature collagen, which often leads to worsening of scars.
Study Design:. Prospective clinical study.
Methods:. One hundred patients with a minimum of 6 months follow-up were recruited. All patients with depressed scars underwent surgery for scar revision. Two weeks before surgical intervention, intramuscular Botulinum toxin was injected around the scar, to prevent movement of the facial muscles. From the second week postsurgery, Cicatrix (Formulation containing activated Centella Asiatica & Pinus Sylvestris, Catalysis, Spain) was routinely used, 3 times a day, for 6 months post the scar revision surgery. Six weeks postsurgery, Fractional C02 laser treatment was started and performed every 4 weeks.
Results:. Using the Objective Assessment Score and the Subjective Assessment Score, the mean of the scores were taken. All patients had satisfactory results, as measured by a patient satisfaction survey and objectively by the physician assessment.
Discussion:. Botulinum toxin injected before scar revision surgery resulted in the wound being stabilized, better wound healing, and prevention of wound widening during healing.
Conclusion:. In view of the results of this study, it is considered worthwhile to offer patients with facial scars, Botulinum toxin injections before scar revision surgery, followed by Fractional C02 laser, along with the routine use of Cicatrix Cream.
... In other studies, BoNTA have been applied intraoperatively  at the time of wound closure or within the first 24 hours [2,. Several clinicians have reported using the toxin after 72 hours , while others injected BoNTA at the time of suture removal (7 to10 days) . In another study, BoNTA was only used at the time of a scar revision . ...
... A dose titration for a novel application of any medicine is always a challenge, and the amount of BoNTA required for the treatment of scars seems to be much lower than traditional doses used for immobilizing muscles and treating wrinkles. The most popular BoNTA doses tried in various studies have been 5 U , 7 U [18,19], and 10 U . In the main, however, these studies do not provide a rationale for their choices. ...
Using Botulinum neurotoxin type A (BoNTA) has yielded promising results in the treatment of immature scars. The biological effects of the toxin on tissue healing appear to be complex and multidimensional and still require additional research. Nevertheless, it is clear that not only does BoNTA reduce muscle tension at the edges of wounds, but it also provides anti-inflammatory effects, promotes angiogenesis and healing, and exerts mediatory or inhibitory effects on a variety of cells. In clinical practice, this pluripotency of BoNTA has been recognized as a therapeutic choice for both prophylaxis and treatment of excessive scarring.
... The initial database search yielded 176 studies. Of these, 26 underwent full-text review and 17 were excluded [6,. Among these excluded studies, three were conducted on animals , four were case reports [14,16,18,21], three were reviews [6,10,17], and another seven lacked raw data or contained useless data [15, (S1 File). ...
... Of these, 26 underwent full-text review and 17 were excluded [6,. Among these excluded studies, three were conducted on animals , four were case reports [14,16,18,21], three were reviews [6,10,17], and another seven lacked raw data or contained useless data [15, (S1 File). Finally, nine articles met the inclusion criteria and were included in the analysis [1,. ...
The purpose of the meta-analysis was to evaluate the efficiency of therapeutic botulinum toxin type A (BTX-A) in the prevention of maxillofacial and neck scars.
Methods and findings:
Information came from the following electronic databases: Medline, PubMed, Cochrane Library, and EMBASE (time was ended by August 31, 2015) to retrieve RCTs evaluating the effect of the BTX-A for hypertrophic scar on the maxillofacial or neck. All languages were included as long as they met the inclusion criteria. Here the effects of BTX-A were evaluated by comparing the width of the scar, patient satisfaction, and the visual analysis scores (VAS), respectively. Pooled weighted mean differences (WMDs), pooled odds ratios (ORs), and 95% confidence intervals (CI) were calculated. Nine RCTs covering a total of 539 patients were included. A statistically significant difference in scar width was identified between the BTX-A group and control group (non-BTX-A used) (WMD = -0.41, 95% CI = -0.68 to -0.14, P = 0.003). A statistically significant difference in patient satisfaction was observed between the BTX-A group and control group (OR = 25.76, 95% CI = 2.58 to 256.67, P = 0.006). And in patients regarding visual analysis scores (VAS), a statistically significant difference was also observed between the BTX-A group and control group (WMD = 1.30, 95% CI = 1.00 to 1.60, P < 0.00001).
This meta-analysis evaluates the efficacy of the BTX-A and confirms that BTX-A is a suitable potential therapy for the prevention of hypertrophic scars in patients in the maxillofacial and neck areas.
... Its use in the field in dermatology has expanded beyond its muscle paralyzing effect improving kinetic wrinkles giving a strong rejuvenating effect. It has shown a scar modulating effect in treating surgical and keloidal scars . ...
Atrophic post-acne scarring constitutes a troublesome cosmetic concern for both patients and dermatologists. Old and new therapies as well as combinations are being introduced to achieve a satisfactory response. Microneedling has been used either alone or under different combinations for its treatment. The aim was to compare its combination with topical platelet-rich plasma versus its combination with topical Botulinum Toxin-A.
30 subjects with different types and grades of atrophic post-acne scars completed the study. Right side of the face was treated with microneedling and platelet-rich plasma while the left side was treated microneedling and Botox. Response was assessed using two different scales. Patient satisfaction and pain were also assessed.
Regarding response to therapy and according to the quartile grading scale, there was no statistically significant difference between the two sides where (23.4% & 13.3%) of the right and left sides, respectively, had an excellent response. Regarding the difference in the qualitative global scarring grading system before and after treatment, there was a highly statistically significant improvement on both sides with higher improvement on the right side than left side but in a non-statistically significant way.
Both combinations present efficacious options for treating acne scars with comparable efficacy.
Registered and approved prospectively by the ethical review board of the faculty of medicine, Zagazig University.
... Recently, MesoBotox has been used for some dermatological indications, including both types of depressed atrophic scars like acne scar and hypertrophic scars, as an adjuvant therapy in combination with other widely used procedures. [50,51] In recent years, botulinum toxin type A (BTA) has been used to treat hypertrophic scar lesions. This toxin affects acetylcholine exocytosis and indirectly blocks neuromuscular transmission, which ultimately leads to muscle relaxation. ...
Scars are among the most prevalent referral cases of dermatology clinics, including atrophic, hypertrophic, or keloidal scars. Approach to scar usually needs a holistic trend, attention to individualized characteristics, and combination therapy. Scars usually need multiple sessions of therapy and the use of combination therapeutic approaches to reach the most acceptable outcomes by safe modalities. Studies on scars are always one of the most important fields of research in medicine, especially in dermatology. For writing this review study, we searched all the databases to find the most relevant and the newest studies related to our topic, because based on expert opinion, this topic may be really practical and interesting for dermatologists and all physicians of various specialties or subspecialties who manage and treat various kinds of scars, including hypertrophic scars and keloids. Based on our results, we concluded that different procedures, which basically use needling, lasers, especially pulsed dye laser (PDL) and carbon dioxide (CO2) laser, and MesoBotox (micro-injection of botulinum toxin), are really promising therapeutic options for hypertrophic and keloidal scars and a combination of these therapies results in more efficacy and lesser side effects in the field of scar management.
... It has also been used in conjunction with other treatment modalities such as intense pulsed light, resurfacing, and fillers, constituting a comprehensive "rejuvenation" plan.  To avoid unwanted action on the deeper muscle, it would be better to inject a low dose (5 units would be sufficient in most cases) of the BTA at the time of the procedure or if desired at suture removal. Care should be especially taken in cases on the cheek and not involving the midline, if not as much on other areas of the body. ...
Facial wounds, especially the ones lying perpendicular to the Lines of Langer, heal poorly. Several methods have been attempted to rectify this, but most of them do not target the underlying pathological process of scarring. Botulinum Toxin-A (BTA) has been successfully used for atrophic and hypertrophic scars.
Materials and methods:
This is a prospective study, where 30 patients who were operated for facial scar revision were divided into two equal groups: The first group was injected with BTA, but the second group was not. They were followed up for three months, and the results were analyzed.
Manchester scar scale (MSS) was used to assess the scars. In all the cases, the MSS score reduced after surgical correction, which further reduced after the injection of BTA in the first group of patients. The results are statistically significant (P < 0.01).
The BTA plays an important role in the treatment of scars after scar revision surgeries.
... Current treatment options for atrophic scarring, include hyaluronic acid (HA)  or polymethylmethacrylate (PMMA) fillers,  chemical peels, 11 ablative or non-ablative laser treatments,  dermabrasion, 14 punch techniques, 17 microneedling 18-21 with or without radiofrequency, 22 fractional micro-plasma radiofrequency, 23 botox, 24 and subcision.  Most of these treatments have limited efficacy, possible side effects, and prolonged downtime. ...
Hyaluronic acid fillers have been studied extensively for facial wrinkles, however their efficacy for atrophic facial scars has yet to be analyzed in a prospective placebo-controlled study.
Analyze the efficacy and safety of a hyaluronic acid filler for atrophic facial scars.
Methods & materials:
Fifteen subjects were randomized to receive up to 1mL of VYC-17.5L on one cheek and up to 1mL of saline on the other side, with an optional touch-up treatment. Subjects were graded by a live blind evaluator using the Quantitative Global Scarring Grading System (QGSGS) [1, 2], the Global Aesthetic Improvement Scale (GAIS), and Canfield photo-analysis.
According to the blind evaluator, there was a significant reduction 90 days after the last treatment on the QGSGS for VYC-17.5L compared to saline (-6.6 VYC-17.5L vs -1.7 saline [t(28)=-4.3196, p=0.008]). There was a smaller, but still significant reduction on the QGSGS for saline alone (10.4 to 8.6 [t(14)=-3.453, p=0.004]). In addition, 93% (13/14) of subjects chose VYC-17.5L over saline treatment and reported an improvement on the GAIS. There were no serious side effects and all minor side effects resolved by day 30.
VYC-17.5L achieved significant improvements in rolling atrophic scars as compared to saline, though saline also had modest improvements.
... 35,36 Some authors have shown satisfactory improvement in the appearance of hypertrophic scars.  Although the treatment of hypertrophic scars and keloids with BoNT appears promising, currently available research is conflicting and does not fully support its use. More rigorous research on the mechanisms of BoNT in pathological wound healing and further evaluation of clinical outcomes are required. ...
Botulinum toxin is integral to the practice of facial plastic surgery. Since it was approved by the U.S. Food and Drug Administration for the temporary improvement of glabellar rhytids in 2002, botulinum toxin has achieved a growing number of off-label clinical applications. These include the management of facial rhytids, brow ptosis, excessive gingival display, masseteric hypertrophy, platysmal banding, facial nerve paralysis, hypertrophic scars, and keloids. Many forms of botulinum toxin have been developed, and their safety and efficacy have been thoroughly established. This article will review the aesthetic and functional uses of botulinum toxin as it relates to the field of facial plastic and reconstructive surgery. In addition, the authors will discuss the suggested quantity of units per injection site based on onabotulinumtoxinA.
... Схожие результаты получили А.М. Wilson  и J.G. Goodman , которые применили хемоде нервацию мышц лба у больных при повторном ис сечении рубца для достижения максимально эф фективного результата. ...
Botulinum toxin has been successfully used in many facial and extra facial regions to limit face muscles movement for aesthetics rids
correction and in other body regions for neurologic and muscles disease. Available literature analysis resumes positive results after bot$
ulinum toxin use for certain types of scars treatment and prophylaxis. Pathophysiology mechanism theories concerning its influence on
scars appearing and formation were formulated. Further in – vitro experimental studies and randomize studies in patients with hyper$
trophic and keloid scars are required to understand botulinum toxin role and effects on scars formation.
... Fractional lasers are certainly not going to substitute for severe volume loss and for the effects of movement on scarred skin where other technologies such as fillers and neurotoxins may be required.  So we are left with box car type scarring and deep rolling scarring as the main targets for deep fractional devices which may be a narrow market if that is our only approach. 3. What histological studies mean when trying to interpret depth effects if they are not performed on the face or to actual areas of post acne scarring? ...
... Ninety percent of patients had an improved outcome with the combination of surgical scar revision and temporary muscular paralysis. Last but not least, BoTN-A has been used to improve acne scars . ...
Botulinum toxin (BTX) has gained a great interest in cosmetic dermatology for its effects on hyperkinetic facial lines. Understanding the basic research and analysis of effects of this potent drug can lead to other possible indications of interest for dermatologists. The use of BTX in focal hyperhidrosis is well established, but BTX has also effects on pain perception, itch and inflammation as discussed in this review.
Acne scars are a source of cosmetic concern for most of the patients.
We sought to compare the clinical efficacy and safety of topical botulinum toxin A (BTX-A) application immediately after microneedling (Mn) versus Mn with saline in the treatment of atrophic acne scars.
Forty patients with atrophic acne scars (rolling, boxcar, and mixed types) were enrolled in a split-face study; microneedling was performed on both sides of the face followed by an application of topically diluted botulinum toxin on one side (Side A) and saline on the other (Side B) for two sessions both two weeks apart. Evaluation was done at baseline, two and four weeks after the session. Follow-up was performed after six months. The assessments included blinded clinical assessment and patient's satisfaction.
After the treatment, acne scars in (Side A) showed 70 percent overall improvement versus zero percent in Side B (P<0.0001). A statistically highly significant reduction of acne scars severity occurred in (Side A) (P=0.0008). Patient's satisfaction was higher in (Side A) (P<0.0001). No serious side effects were reported.
Microneedling delivery of BTX-A could be simple, safe, and innovative modality improving the appearance and decrease the depth of atrophic acne scars.
The tracheostoma always requires special care to maintain its function and to avoid complications. Saliva, secretion and cannula movements can cause irritation of the tracheostoma. This chapter deals specifically with the diagnosis and therapy of wound infections caused by bacteria and fungi, incrustation and local bleeding. Special problems with pre-existing skin diseases and allergic mucous membrane reactions are discussed in detail. Attention is paid to the often-occurring scars and keloids on the stoma with important prophylaxis and therapy instructions. In order to secure the function and avoid complications in tracheostoma patients, the requirement of care standards and care algorithms is pointed out on the basis of examples.
BoNT/A currently has many uses, both on- and off-label, and the number of indications continue to grow. The United States Federal Drug Administration (FDA) approved dermatologic uses including axillary hyperhidrosis (excessive underarm sweating), glabellar and forehead rhytids, and lateral canthal lines (crow’s feet). Off-label dermatologic uses include lower face treatment, acne, rosacea, scar reduction, pain, and psoriasis.
Acne is a very common inflammatory disease with superimposed opportunistic infection, which, if left untreated, will often lead to lifelong scarring. The resultant scarring is graded for the purposes of classification and communication, but the scarring is a very individual issue with even minor scarring a great issue for patients.
The addition of a chapter on “Traumatic and Burn Scars” in the second edition of this text is an acknowledgment of the interval emergence of minimally invasive technologies and techniques in traumatic scar management (e.g., ablative fractional laser resurfacing) and perhaps even a nascent niche in “trauma dermatology.” Traumatic scars are inherently heterogeneous and derived from a wide variety of etiologies such as thermal burns, friction injuries, acid burns, lacerations, and blunt force. The final presentation also includes the sequelae of any related reconstructive procedures such as full- and partial-thickness skin grafting. These scars may occur in an unlimited number of locations and may have associated underlying injuries such as tissue loss and injury to bones, tendons, and nerves. Traumatic scars can cause profound disability, deformity, and chronic pain and itch, all of which may lead to significant psychosocial issues that can negatively impact treatment.
Das Tracheostoma bedarf stets einer besonderen Pflege zum Funktionserhalt und zur Vermeidung von Komplikationen. Durch Speichel und Sekretaustritt sowie Kanülenbewegungen können Irritationen am Tracheostoma ausgelöst werden. Das Kapitel befasst sich speziell mit Diagnostik und Therapie von Wundinfektionen durch Bakterien und Pilze, Borkenbildungen und lokalen Blutungen. Spezielle Probleme bei vorbestehenden Hauterkrankungen und allergischen Schleimhautreaktionen werden eingehend besprochen. Besondere Beachtung finden die nicht selten auftretenden Narben und Keloide am Stoma mit wichtigen Prophylaxe- und Therapiehinweisen. Zur Sicherung der Funktion und Vermeidung von Komplikationen bei Tracheostoma-Patienten wird auf das Erfordernis von Pflegestandards und Pflegealgorithmen anhand von Beispielen hingewiesen.
Pathologic scars remain a therapeutic enigma. Several therapeutic modalities have been described for the prevention and treatment of hypertrophic and keloid scars, but the optimal management approach has not yet been defined. This article reviews the newly emerging, off-label treatment, botulinum toxin-A (BTXA) for scar reduction. Eight in vitro, 9 in vivo animal, and 23 human clinical studies were deemed relevant to this review. Studies were conducted between 2000 and 2018. Clinical studies were of various methodologic qualities and comprised of 8 blinded randomized control trials, 7 cohort studies, and 7 case series/reports. Across all 23 human clinical studies, 521 patients were recruited, 20 studies were in favor of BTXA to reduce scars, 2 studies had equivocal results, and 1 study showed no benefit. The efficacy of BTXA to reduce scars appears promising and the clinical literature currently favors its use over placebo controls as a safe scar reduction alternative. The efficacy of this modality in comparison with other more widely accepted scar reduction methods is less clear. Further understanding of the molecular mechanism of action of BTXA upon scars and treatment modality cost-effectiveness comparisons remain to be explored. Large-scale randomized control trials of high methodologic quality, using objective measurement scales, must be produced to truly determine the efficacy of this innovative treatment.
The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.
Glabella facial expressions are acquired by age, solar radiation, and muscle contraction, and are common reasons for great concern and dermatological consultations. Some patients reject the use of botulinum toxin or filler materials, so a great alternative now is subcision, a technique that is now modified having better results by adding miotomy to the corrugators.
Postoperative care protocols vary considerably and are often based on individual experiences, rather than any rigorous evidence base. Patients may be followed up for only a month or two, or they may be kept under review for a number of years depending on the surgeon’s interest, ongoing complications and need for further surgery. Yet one can argue that long-term follow-up is essential to enable us to assess long-term outcomes, necessary for “quality control.” How can we say we are “good” at anything, if we don’t see and critically analyse the long-term results? Lack of complications does not necessarily mean a good outcome. Nevertheless, a pragmatic approach is often required, particularly in centres where high volumes of trauma and limited resources make it impossible to provide long-term follow-up for every patient.
Acute otitis media (AOM) is a common illness in childhood and becomes recurrent in up to 20%. Recurrent acute otitis media (RAOM) is associated with significant negative impact on quality of life for the affected child and their care-givers. This review article considers the definition, epidemiology, and pathogenesis of RAOM in children. It focuses in particular on the investigation of children referred to the ENT clinic and treatment options available taking into consideration recent updates to the evidence base.Optimal management of RAOM remains a clinical challenge. A logical stepwise approach to management considering all treatment modalities including modification of risk factors is appropriate. Research priorities in the management of RAOM include the role of adenoidectomy and its relative benefits in different age groups of children and the optimal antibiotic for prophylaxis and duration of prophylaxis.
Key words: Otitis media, recurrent acute otitis media, children
J ENT Masterclass 2014; 7 (1): 5 - 9.
The use of botulinum toxin in Otorhinolaryngology has rapidly expanded over the last decade. Current observation is that the use of botulinum toxin in Otorhinolaryngology is relatively poorly acknowledged by Otorhinolaryngologists.
Objective of review:
To summarise the non-cosmetic uses of botulinum toxin in Otorhinolaryngology.
Type of review:
Search strategy and evaluation method:
A literature search was performed using the Medline and Embase databases. Combinations of 'botulinum toxin' with each indication were searched. A citation was included if it evaluated a non-cosmetic use of botulinum toxin in Otorhinolaryngology. Eligibility of studies was assessed by two reviewers. A total of 1187 abstracts were reviewed and 97 articles identified.
Botulinum toxin provides an effective and minimally invasive treatment option in a wide range of non-cosmetic indications. Side-effects are few and transient with an excellent safety profile. Ongoing research is required to fully critically appraise its uses.
Background: Bacterial lipopolysaccharide (LPS) is the major component of outer leaflet of cell
wall of most gram negative bacteria that has been surge of interest in immunological and
inflammatory studies. The proliferation of fibroblasts is one of the inevitable events in wound
healing process. Skin is the first barrier in immune response which is more susceptible to
inflammation. The aim of this survey was the evaluation of effects of Salmonella enterica LPS
on skin fibroblasts proliferation.
Material and methods: Fibroblast cells were plated at 3×105
cells/well in a 96 well culture
plate. Cells treatment was performed in two groups. The first group treatment was immediately
and in the second group After an overnight culture period in standard conditions were treated
with different concentrations of Salmonella enterica LPS (1, 3.16, 10, 31.6, 100μg and 3.16, 10,
31.6, 100, 316ng) for 24, 48 and 72 hours. Effects of LPS on the activation of mitochondrial
dehydrogenase were examined by XTT assay which were more save, accurate, easy to use than
MTT assay. Cell viability was determined by Trypan blue.
Results: Data obtained from XTT assay indicated that different concentrations of Salmonella
enterica LPS had no toxic effects on fibroblasts. ANOVA test showed significant difference in
The management of scarring (after acne, surgery, or disease) is an ongoing challenge.
This is the second of two reviews and will use a grading scale of disease burden to classify scarred patients. Treatment discussion will concentrate on procedures exerting effect on volume and surface changes and the effects of movement.
Treatment relevant to the type and severity of scarring will be discussed and tabulated treatment plans outlined.
Severe grades of scarring often require a combination of filling agents for volume deficit, injectable agents for hypertrophic disease, neurotoxins to effect movement, and fractionated and ablative resurfacing for surface changes.
Post-acne scarring remains a common entity despite advances in the treatment of acne. This represents limitations in our quality of therapy and a failure of public education. The level of severe scarring remains as much an ongoing challenge to prevent as well as manage.
This review will concentrate on the methods by which acne scarring may be improved and the available evidence for their utility. It will also rely on a grading scale of disease burden to classify patients and their ideal therapy. New therapies allowing treatment of scarring in areas other than the face will also be highlighted. Results: Tabulated treatment planning will present algorithms summarizing best practice in the treatment of post-acne scarring.
Post-acne scarring is being better managed. Grade 1 scars with flat red, white, or brown marks are best treated with topical therapies, fractionated and pigment or vascular-specific lasers and, occasionally, pigment transfer techniques. Grade 2 mild scarring as seen primarily in the mirror is now the territory of non-ablative fractionated and non-fractionated lasers as well as skin rolling techniques. Grade 3 scarring, visible at conversational distance but distensible, is best managed by traditional resurfacing techniques or with fractional non-ablative or ablative devices, sometimes including preparatory surgical procedures. Grade 4 scarring, where the scarring is at its most severe and non-distensible, is most in need of a combined approach.
Clostridial neurotoxins, including tetanus toxin and the seven serotypes of botulinum toxin (A-G), are produced as single chains and cleaved to generate toxins with two chains joined by a single disulphide bond (Fig. 1). The heavy chain (M(r) 100,000 (100K)) is responsible for specific binding to neuronal cells and cell penetration of the light chain (50K), which blocks neurotransmitter release. Several lines of evidence have recently suggested that clostridial neurotoxins could be zinc endopeptidases. Here we show that tetanus and botulinum toxins serotype B are zinc endopeptidases, the activation of which requires reduction of the interchain disulphide bond. The protease activity is localized on the light chain and is specific for synaptobrevin, an integral membrane protein of small synaptic vesicles. The rat synaptobrevin-2 isoform is cleaved by both neurotoxins at the same single site, the peptide bond Gln 76-Phe 77, but the isoform synaptobrevin-1, which has a valine at the corresponding position, is not cleaved. The blocking of neurotransmitter release of Aplysia neurons injected with tetanus toxin or botulinum toxins serotype B is substantially delayed by peptides containing the synaptobrevin-2 cleavage site. These results indicate that tetanus and botulinum B neurotoxins block neurotransmitter release by cleaving synaptobrevin-2, a protein that, on the basis of our results, seems to play a key part in neurotransmitter release.
Facial laser resurfacing and chemodenervation with botulinum toxin type A are used independently as means of nonsurgical facial rejuvenation. Recent reports in the literature have described combining these 2 therapies, claiming improved and longer-lasting laser resurfacing results. To date, no scientific investigation has been undertaken to prove or disprove this theory.
Institutional review board-approved, prospective, randomized, blinded study at university-affiliated outpatient cosmetic surgery offices.
Patients had one side of their face injected, at specific anatomic subsites (crow's feet, horizontal forehead furrows, and glabellar frown lines), with botulinum toxin 1 week before laser resurfacing. After receiving an injection, patients underwent cutaneous laser exfoliation on both sides of the face with either a carbon dioxide or an erbium dual-mode laser.
Patients' injected (experimental) and noninjected (control) sides were compared after laser resurfacing. Follow-up was documented at 6 weeks, 3 months, and 6 months after laser resurfacing. Subjective evaluation, based on a visual analog scale, was performed in person by a blinded observer. Furthermore, a blinded panel of 3 expert judges (1 facial plastic surgeon, 1 oculoplastic surgeon, and 1 cosmetic dermatologist) graded 35-mm photographs taken during postoperative follow-up visits.
Ten female patients were enrolled in the study. A 2-tailed t test showed that all sites that were pretreated with botulinum toxin showed statistically significant improvement (P< or =.05) over the nontreated side, with the crow's feet region showing the greatest improvement. Comparing results between the carbon dioxide and erbium lasers did not result in any statistically significant differences.
Hyperdynamic facial lines, pretreated with botulinum toxin before laser resurfacing, heal in a smoother rhytid-diminished fashion. These results were clinically most significant in the crow's feet region. We recommend pretreatment of movement-associated rhytides with botulinum toxin before laser resurfacing. For optimum results, we further recommend continued maintenance therapy with botulinum toxin postoperatively.
Tensile distracting forces caused by elements such as a muscle pull can cause widening of scars in the tissue during the wound healing process. The aim of the present study was to investigate whether induced immobilization of the urethral muscle using botulinum toxin-A (BTX-A) enhances wound healing and also reduces the amount of scar formation in an experimentally induced urethral injury in a male rat model.
Prepubertal male albino rats were divided into 2 groups: 20 rats in the BTX-A group received BTX-A injection treatment during surgery and 10 rats in the control group received 0.9% saline solution injection. The penile skin was incised circumferentially and degloved. To make the urethral injury at a location approximately 15 mm proximal to the external meatus, the urethra was cut transversally with scissors, from the 2-o'clock to the 10-o'clock position and then sutured by a single suture at the 6-o'clock position. To evaluate chronic inflammation and fibrosis, the rats were killed, and the injured portions of the urethras were harvested for histopathologic examination after a follow-up period of 21 days.
On histopathologic evaluation, the control group rats had a more severe fibrotic change in the urethral tissue compared with the BTX-A injected rats, which showed a mild fibrotic change. The mean +/- SD and median fibrosis score was 2.4 +/- 0.5 and 2 in the control group and 1.5 +/- 0.5 and 1 in the BTX-A group, respectively (P < .01 and P < .01, respectively).
The results of our study have shown that BTX-A prevented increases in collagen content during urethral wound healing.
Eighteen patients with glabellar frown lines were treated with C. botulinum-A exotoxin. Sixteen of the 17 patients followed showed improvement for periods ranging from 3 months to 11 months. Side-effects were minimal and transient. Because C. botulinum-A exotoxin therapy of glabellar frown lines treats the underlying cause of these lines, it is more effective than soft tissue augmentation although this improvement is temporary. Treatment with C. botulinum-A exotoxin is a simple, safe procedure.
At this time no effective long-term therapy exists for the excessive secretion of vasomotor rhinitis. Because rhinorrhea is under parasympathetic control, it was theorized that botulinum toxin--a powerful and long-acting cholinergic blocker that has been successful in the treatment of dystonia--might be useful in blocking the cholinergic control of rhinorrhea. Four male mongrel dogs were studied. Fifty units of type A botulinum toxin was soaked into sterile gauze, which was then packed into the left nasal cavity of each dog for 1 hour. Saline-soaked gauze was similarly introduced into the right nasal cavity to serve as control. Six days later, rhinorrhea was produced by inserting a bipolar needle electrode into the sphenopalatine ganglion and electrically stimulating for 10 minutes (6 mA, 50 Hz). Nasal secretions were collected with a suction catheter placed in the nasal vestibule. Three of four dogs exposed to the toxin showed a 41% average decrease in rhinorrhea (specifically 53%, 41%, and 30%). One dog showed a 10% increase in secretion after exposure to the toxin. We conclude that topically applied botulinum toxin reduced neurally evoked rhinorrhea by an average of 41%. Because some secretion is mediated by noncholinergic neurotransmitters such as vasoactive intestinal peptide, topical application of an anticholinergic substance has limitations. However, because all the nasal parasympathetic nerves appear to originate from cholinergic synapses in the sphenopalatine ganglion, direct injections of toxin into this ganglion may possibly allow complete blockade of all cholinergically mediated rhinorrhea.
Previous work on patients with muscular dystonia has shown that small intramuscular doses of botulinum toxin A eliminated hyperkinetic facial lines for approximately 6 months. The purpose of this study was to determine the efficacy of botulinum toxin A injections in eliminating facial wrinkles in aesthetic surgery patients who do not have muscular dystonia. Eleven healthy subjects were studied in a double-blind fashion. On both sides of the face, 0.2 cc of either normal saline or botulinum toxin A was injected into the forehead or into the periorbital wrinkles (crow's feet). Documentation of results was made by photographs taken of the patients during repose and during facial animation before and after injection. Assessment of facial wrinkles was done from a grading system in which the patient and the facial plastic surgeon were asked to judge the severity of the wrinkles on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Nine of 11 subjects injected with botulinum toxin A noted a significant improvement in the severity of their facial wrinkles in comparison with the side of the face injected with saline, with a rating improvement of 2 points. Two of 11 subjects noted a moderate improvement, with a rating improvement of 1 point. No patient injected with saline reported an improvement in the severity of the facial wrinkles on the control side. There were no serious complications. Botulinum toxin A is an efficacious method of nonsurgically eliminating facial wrinkles and may play a role in the cosmetic enhancement of the aging face.
A clinical trial was undertaken to evaluate the effects of commercially available botulinum toxin on 14 hyperactive corrugator muscles, 14 procerus muscles, one case of congenital aplasia of the depressor labii inferioris muscle, and one case of iatrogenic injury to the ramus mandibularis branch of the facial nerve with paralysis of the depressor labii and mentalis muscles. Of the 31 muscles injected, 28 were appropriately paralyzed with the initial injection. The desired results were obtained in the 3 remaining muscles following a second injection. The ability to frown was nullified in all subjects, resulting in the elimination of glabellar lines. Facial symmetry was achieved in both patients with muscle imbalance. The average duration of the paralysis was 8 weeks, with a range of 2 to 16 weeks. However, this period was prolonged in the latter part of the study with an adjustment of the toxin dose. Our results demonstrate that botulinum toxin injected into overactive facial muscles does produce a predictable and reversible paralysis and eliminates or ameliorates deep frown lines. We also illustrate its use in achieving facial symmetry in one patient with congenitally absent depressor labii inferioris and platysma muscles and in another with postrhytidectomy facial nerve paralysis.
Botulinum A chemodenervation of the Adductor Pollicis muscle for the treatment of the thumb-in-palm deformity in cerebral palsied hands is presented as a new therapeutic option. Early results of a clinical trial in five hemiparetic Cerebral Palsied (C.P.) children are assessed using a prospective nontrialist-biased study design based on an independent panel assessment of pre- and post-intervention photographic and videotaped records of hand function and appearance, in combination with grip dynamometry and goniometry. All cases are shown to improve in terms of both function and appearance with results approaching statistical significance (p = 0.06) when assessed by the Wilcoxon's matched-pairs signed rank test, despite the small study group. The modality is shown to be simple, safe and effective over the period reported (229 days). The benefit is sustained beyond the period of muscle paresis and ongoing long term follow-up will document the need for, and timing of, reinjection.
The present article illustrates the effects of low dose botulinum toxin (BTx) injections for the improvement of hyperkinetic facial lines and presents a grading treatment chart designed to standardize the reporting of the improvement seen. A questionnaire of patient acceptance, the patients' impression of therapy and short-term results and complications are reported. Twelve patients with 26 injected-paired regions were charted and the response to injection was graded. Patients had hyperkinetic facial lines in glabella, periorbital regions or horizontal forehead lines. Diluted BTx type A (1 IU/0.1 mL) was injected and patients were assessed at 10 days. A second follow up injection was offered to patients at this stage if required. Objectively, all patients' hyperkinetic actions and lines improved or diminished. The degree of improvement was similar in all areas injected and a symmetry of results was always observed. In a minority of cases, all movement was lost (7/26) and in others it was weakened but present (19/26). In some injected areas the actual expression line that was visible at rest disappeared entirely (11/26): in the others it was diminished (15/26). Complications were few. Two patients had temporary brow ptosis that spontaneously recovered within the first week. No eyelid ptosis was noted. Bruising and headaches were the most common reported complications. Low dose BTx is an effective and well-tolerated treatment for hyperkinetic facial lines with few significant complications in this small pilot study. The grading chart may allow easier comparisons of results between studies on the effects of BTx therapy.
Surgeons have constantly sought to achieve the most aesthetic scar. A major factor determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. Since Theodor Kocher pioneered the alignment of skin incisions with Langer's lines in 1892, surgical techniques that attempt to overcome closing tension have become standard. Yet, no treatment has been available to minimize underlying muscle contractions, which are the major cause of this tension. Botulinum toxin A is a potent drug that produces temporary muscular paralysis when injected locally. It has proven to be safe and effective in the treatment of a variety of disorders, including hyperkinetic facial lines. The objective of this randomized, double-blind, placebo-controlled primate study was to investigate the efficacy of a single injection of botulinum toxin A to improve the cosmetic appearance of cutaneous scars. Symmetric pairs of standardized excisions were performed on either side of the forehead of six primates. The half foreheads were randomized to the botulinum toxin A treatment side versus the placebo injection side. A panel of three blinded facial surgeons assessed the cosmetic appearance of the mature scars 3 months postoperatively. The wounds that had been immobilized with botulinum toxin A were rated as significantly better in appearance than the control wounds (p < 0.01). Histologic examination confirmed that all scars were mature. Blinded, randomized, placebo-controlled human clinical trials are presently under way at the Mayo Clinic.
Acne is a common condition experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults. In some patients, the severe inflammatory response to Propionibacterium acnes results in permanent, disfiguring scars. Over the past several decades, numerous descriptive terms and surgical techniques have been used to diagnose the types, and improve the appearance, of scarring in those persons with acne. We propose a descriptive, simple, universally applicable acne scar classification system that includes 3 scar types: icepick, rolling, and boxcar. We also have developed an effective treatment algorithm for reconstructing and improving the appearance of acne scars including punch excision, punch elevation, subcutaneous incision (Subcision), and laser skin resurfacing. This new classification system for acne scars enables the physician to more precisely identify scar subtypes. Once the scar type has been defined, appropriate and effective treatment protocols can be developed.
Botulinum toxin injection has been used for a variety of indications in humans, including blepharospasm and hyperfunctional facial lines. This article describes a novel formulation of botulinum toxin, which supplies immediate feedback to the injecting physician. Additionally, recent findings are described that indicate the immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of the facial cutaneous scar. Future applications of these findings are discussed.
An increasing number of media reports on patient safety risks arising from office-based surgery procedures, as well as growing concerns about patient safety issues in general, have brought office-based surgery as well as its practitioners into focus and placed this very cost-effective medical practice in the eye of the media and regulators. Concerted efforts are now being made to understand the causes and true incidence of patient safety risk associated with office-based surgery and to find ways to minimize this risk.
Botulinum toxin adequately treats hyperkinetic facial lines and hyperhidrosis. Higher doses of botulinum toxin appear to enhance efficacy and longevity possibly through greater evenness of diffusion; however, recurrent treatments with higher doses are expensive.
To admix botulinum toxin with hyaluronidase and to test whether there is maintenance of efficacy, a spread of effect, and possibly a decrease in required dose compared with botulinum toxin.
Six patients participated in a double-blinded side-to-side comparison pilot study with photographic analysis for frontalis overactivity and Minor's iodine and gravimetric testing for axillary hyperhidrosis.
Initial efficacy of botulinum with admixed hyaluronic acid appeared maintained with possibly increased diffusion when hyaluronic acid is added. No difference was evident on short-term review of patients treated with 50 U of botulinum in one axilla compared with the contralateral side injected with 25 U with admixed hyaluronidase.
There may be a role for hyaluronic acid in aiding diffusion and decreasing the required dose of botulinum toxin in hyperhidrosis axillaris.
Wounds of the face, especially those lying perpendicular to the lines of Langer, are known to heal poorly with conspicuous scarring. Different methods have been tried to tackle this problem, including corticosteroid injections, irradiation, ultrasound, silicone applications, and many others. However, as expected, their effects were far from satisfactory, because they do nothing to alleviate the underlying pathologic process, which is the distracting effect of muscle pull on immature collagen.
In 40 patients with ugly scars of the face, botulinum toxin was used to induce temporary paralysis of the muscles during revision surgery, thus minimizing tension on healing wound edges until the collagen could mature.
Using both objective and subjective assessment scales, 90 percent of patients ended up with an improved outcome. This new technique has been proven effective in primates and in this study was shown to be as effective in humans, yielding results superior to those of any other treatment modality.
In view of the results of this study, it is considered worthwhile to offer patients with ugly scars of the face botulinum toxin injections simultaneous with revision surgery.
Until relatively recently, restoration of appearance by replacement of lost facial volume and muscular relaxation has been an illusory goal. With advances in the commercial availability of newer filling agents and a better understanding of the clinical esthetic effects of botulinum toxin A, remarkably sophisticated and refined results can now be achieved by using these noninvasive techniques. The combined use of BTX-A and filling agents, such as collagen and hyaluronic acid, can restore facial appearance by the dual mechanisms of reflation and relaxation. In addition, their combined use appears to increase the longevity of tissue dwell time of the filling agent. Current practices now strive to correct wrinkles by restoring volume and also relaxing the pull of muscles that create negative facial expressions such as glabellar folds, mouth frown, crow's feet, horizontal forehead lines, and perioral and cervical rhytides. As with any of the new technological innovations currently available, understanding of the differing properties of the agents used and education in optimal technique is essential to clinical and esthetic success.
To test whether botulinum toxin-induced immobillzation of facial lacerations enhances wound healing and results in less noticeable scars.
In this blinded, prospective, randomized clinical trial, patients were randomized from February 1, 2002, until January 1, 2004, to botullnum toxin vs placebo injection into the musculature adjacent to the wound within 24 hours after wound closure. Blinded assessment of standardized photographs by experienced facial plastic surgeons using a 10-cm visual analog scale served as the main outcome measure.
Thirty-one patients presenting with traumatic forehead lacerations or undergoing elective excisions of forehead masses were included in the study. The overall median visual analog scale score for the botulinum toxin-treated group was 8.9 compared with 7.2 for the placebo group (P=.003), indicating enhanced healing and Improved cosmesis of the experimentally immobilized scars.
Botullnum toxin-induced Immobilization of forehead wounds enhances healing and is suggested for use in selected patients to improve the eventual appearance of the scar.
There is no global qualitative grading system for assessing the disease load and global severity of disease in a patient with postacne scarring.
The purpose of this article is to provide a simple qualitative grading system that would allow better communication between practitioners of a patient's global disease severity and the most appropriate corresponding therapy for that degree of acne scarring.
Four grades of postacne scarring are described, and appropriate therapeutic interventions are presented for each. Grade assignment is made by lesion morphologies and disease load as indicated by patient perception of severity (i.e., whether or not an individual can easily disguise his or her disease at social distances).
A simple qualitative global acne scarring grading system is presented.
The determination of disease load in terms of patient perception of severity is intrinsically imperfect due to varying subjectivity among individuals.
A global acne scarring grading system is presented that is simple to use and may optimize therapeutic intervention. This system would also allow investigators, educators, and proceduralists to compare their cases more accurately and to have a more objective discussion of the efficacy of operative interventions or therapies.
This study aimed to investigate the effects of intra-articular botulinum toxin in preventing arthrofibrosis. Arthrofibrosis was induced in both stifle joints of 20 rabbits by transecting the anterior cruciate ligament under intramuscular anesthesia with ketamine and xylazine. Intra-articular toxin at a dose of 0.6 ml (50 unit) and physiologic saline solution (0.6 ml) were injected into the right and left stifle joints, respectively, 3 times with a 1-week interval between each injection. The rabbits were euthanized in the 12th week via high dose anesthesia to remove the stifle joint. The severity of adhesions was assessed, applying a universal scoring system. Also the stifle joints were histologically evaluated for fibrosis. With regards to severity of adhesion a significant reduction in the adhesion score was observed in the toxin-treated group in comparison to untreated controls with mean +/- SE values of 0.2 +/- 0.1 and 2.4 +/- 0.2, respectively (p < 0.01). The histological evaluation showed no significant fibroblast in the toxin-treated group versus dense fibers with mature fibroblasts in the control group. Our results suggest that botulinum toxin demonstrated efficacy in preventing adhesion after knee surgery and all the parameters monitored showed consistent statistically significant improvement.
Broadband light (BBL; Intense Pulsed Light; Lumenis Ltd., Yokneam, Israel) is a powerful, nonablative, light-based technology that targets melanin and hemoglobin and stimulates the formation of collagen and elastin. Botulinum toxin type A (BTX-A; BOTOX; Allergan Inc., Irvine, CA) treatment of the lateral periocular region relaxes the vertical fibers of the orbicularis oculi and results in softening of the lateral orbital crow's feet rhytides and widening of the palpebral aperture.
To compare the effects of full-face BBL in combination with BTX-A and BBL alone in female subjects with Fitzpatrick I-III skin types, Glogau II-III rhytides, and significant associated facial lentigines and telangiectasia.
This was a prospective, randomized study of 30 women with moderate to severe crow's feet rhytides. Half of the subjects were treated with BTX-A and BBL and the other half with BBL alone. Their response was assessed clinically and photographically. Skin biopsies of the temporal skin were taken from two subjects in each group and were stained with Masson trichrome.
Patients treated with a combination of BTX-A and BBL experienced a better response to treatment, both at rest and on maximum smile, as well as a slightly improved response in associated lentigines, telangiectasia, pore size, and facial skin texture compared with patients who received BBL treatment alone. Skin biopsies showed an increase in dermal collagen in each group.
The patients in this study benefited from both treatments. Although BBL led to a remarkable improvement in full-face telangiectasias, lentigines, and skin texture, the improvement increased in all categories with combination therapy. In addition, an added improvement in the full-face aesthetic with both BTX-A and BBL therapy combined was obvious. These results suggest that both treatments--although evidently complementary--may also act synergistically to produce optimal clinical effects, revolutionizing the treatment of facial aging.