The management of hyperfunctional facial lines with botulinum toxin. A collaborative study of 210 injection sites in 162 patients

Glabellar rhytids in thyroid-associated orbitopathy

PURPOSE

To correlate the presence and severity of glabellar rhytids with disease severity in patients with thyroid-associated orbitopathy (TAO).

METHODS

Retrospective, noncomparative medical record review of 113 consecutive new patient visits with the clinical diagnosis of TAO. Ocular examination features studied included assessment of visual acuity, optic nerve appearance and function, proptosis, strabismus, eyelid position, and exposure keratopathy. These features were correlated with graded clinical photographs evaluating rhytid severity using the Fisher exact text.

RESULTS

Eighty of 97 patients included in the study (82.5%) had glabellar rhytids. Eyelid retraction was present in 95 of the 97 patients (98%). Patients with diplopia had more severe rhytids (p < 0.05). Patients with at least three abnormal clinical findings tended to have more severe rhytids.

CONCLUSIONS

Glabellar rhytids are a common finding in patients with TAO, and tend to be present in patients with diplopia and multiple stigmata of the disease.

Botulinum toxin: basic science and clinical uses in otolaryngology

The role of botulinum toxin as a therapeutic agent is expanding rapidly in otolaryngology. Botulinum toxin is a protease that blocks the release of acetylcholine from nerve terminals. Its effects are transient and nondestructive, and largely limited to the area in which it is administered. These effects are also graded according to dose, allowing for individualized treatment of patients and disorders. Botulinum toxin has been used primarily to treat disorders of excessive or inappropriate muscle contraction. In the field of otolaryngology, these include spasmodic dysphonia, oromandibular dystonia, and blepharospasm; vocal tics and stuttering; cricopharyngeal achalasia; various tremors and tics; hemifacial spasm; temporomandibular joint disorders; and a number of cosmetic applications. Botulinum toxin treatment has recently begun to show some benefit in the control of pain from migraine and tension headache. It may also prove useful in the control of autonomic dysfunction, as in Frey syndrome, sialorrhea, and rhinorrhea. In over 20 years of use in humans, botulinum toxin has accumulated a considerable safety record, and in many cases represents relief for thousands of patients unaided by other therapy.

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.

Addition of an anesthetic agent to enhance the predictability of the effects of botulinum toxin type A injections: a randomized controlled study

OBJECTIVE

To determine whether the paralyzing effect of botulinum toxin type A reconstituted in a solution of lidocaine with epinephrine is as effective as that of the same toxin reconstituted in saline and to determine whether the addition of lidocaine with epinephrine enhances the predictability of outcomes of botulinum toxin injections.

SUBJECTS AND METHODS

This double-blind, within-subject, randomized controlled study was conducted in 10 volunteer subjects. Lidocaine was added to botulinum toxin type A to achieve an immediate paralyzing effect on the injected muscle, and epinephrine was added to minimize diffusion of the injected toxin to adjacent muscles. This combination of agents was injected to temporarily paralyze the frontalis, corrugator supercilii, and procerus muscles on 1 side of the forehead of the 10 volunteers. The contralateral side was injected with the same dosage of the toxin, reconstituted in an equal volume of saline, to serve as control. Photographic and video documentation of the drugs' effects was obtained before injection and at 5 to 10 minutes, 1 week, and 3 months after the injections.

RESULTS

Immediate paralysis ensued on the experimental side (botulinum toxin type A + lidocaine + epinephrine) in all 10 volunteers. As assessed by 3 blinded evaluators, the extent of immediate paralysis resulting from the anesthetic agent was predictive of the extent of delayed paralysis resulting from the botulinum toxin. The botulinum toxin-induced paralysis wore off symmetrically in all subjects.

CONCLUSION

The injection of botulinum toxin reconstituted in lidocaine with epinephrine provided the physician immediate feedback on the extent of paralysis to be expected from the chemodenervating action of the botulinum toxin. This may enhance the safety and predictability of botulinum toxin injections in many applications.

Complications of botulinum A exotoxin for hyperfunctional lines

Clostridium botulinum type A exotoxin is one of the recent advances for treatment of the aging face. Due to the sudden and exponential surge in popularity, there is little precise consensus regarding its safety and efficacy. Many of the reported complications associated with its aesthetic use are few and anecdotal. As we gain more experience and long-term follow-up with this procedure, complications and their treatment can be better documented. As most of the salutary effects of Botulinum toxin are temporary, fortunately, so too are the complications associated with this form of therapy.

Treatment of hyperfunctional lines of the face with botulinum toxin A

Since Botulinum toxin A became a mainstay therapy for blepharospasm, its use in treating other dystonic conditions, spasticity disorders, as well as hyperfunctional lines of the face has increased exponentially in recent years. The following article summarizes our experience in establishing a safe and reliable method of administration of botulinum toxin A for treating hyperfunctional lines of the face.

Botulinum A neurotoxin for axillary hyperhidrosis. No sweat Botox

BACKGROUND

Axillary hyperhidrosis causes considerable emotional stress and is associated with extraordinary costs and limitations in clothing. Existing topical and surgical therapies are either ineffective or associated with unacceptable morbidity and sequelae. Botulinum A neurotoxin (Botox) has been shown to decrease sweating in normal skin and in palmar hyperhidrosis.

OBJECTIVE

The current study was undertaken to demonstrate the utility of using Botox in the treatment of axillary hyperhidrosis.

METHODS

Twelve patient with axillary hyperhidrosis underwent intradermal injection with 50 units of Botox in the axillary skin bilaterally.

RESULTS

All patients enjoyed relatively complete anhidrosis of the axillary skin in periods ranging from 4 to 7 months. Repeat injections produced similar results.

CONCLUSION

Botulinum A neurotoxin (Botox) is an elegant and simple treatment for axillary hyperhidrosis.