1
|
Dirr MA, Christensen RE, Anvery N, Nadir U, Schaeffer M, Veledar E, Minkis K, Nodzenski M, Whittington A, Brieva JC, Tung R, Poon E, Alam M. Pain of local anesthetic injection of lidocaine during subsequent stages of Mohs micrographic surgery: A multicenter prospective cohort study. J Am Acad Dermatol 2023; 89:114-118. [PMID: 36907555 DOI: 10.1016/j.jaad.2023.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/26/2023] [Accepted: 02/25/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Patients awake during staged cutaneous surgery procedures may experience procedure-related pain. OBJECTIVE To determine whether the level of pain associated with local anesthetic injections prior to each Mohs stage increases with subsequent Mohs stages. METHODS Multicenter longitudinal cohort study. Patients rated pain (visual analog scale: 1-10) after anesthetic injection preceding each Mohs stage. RESULTS Two hundred fifty-nine adult patients presenting for Mohs who required multiple Mohs stages at 2 academic medical centers were enrolled; 330 stages were excluded due to complete anesthesia from prior stages, and 511 stages were analyzed. Mean visual analog scale pain ratings were nominally but not significantly different for subsequent stages of Mohs surgery (stage 1: 2.5; stage 2: 2.5; stage 3: 2.7: stage 4:2.8: stage 5: 3.2; P = .770). Between 37% and 44% experienced moderate pain, and 9.5% and 12.5% severe pain, during first as versus subsequent stages (P > .05) LIMITATIONS: Both academic centers were in urban areas. Pain rating is inherently subjective. CONCLUSIONS Patients did not report significantly increased anesthetic injection pain level during subsequent stages of Mohs.
Collapse
Affiliation(s)
- McKenzie A Dirr
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rachel E Christensen
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Noor Anvery
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Umer Nadir
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matthew Schaeffer
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Emir Veledar
- Center for Advanced Analytics, Baptist Health South Florida, Florida; Department of Biostatistics, Robert Stempel College of Public Health, Miami, Florida; Department of Biostatistics, Florida International University, Miami, Florida; Division of Cardiology Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Kira Minkis
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Michael Nodzenski
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adam Whittington
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Joaquin C Brieva
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rebecca Tung
- Department of Dermatology, University of Central Florida, Orlando, Florida; Florida Dermatology and Skin Cancer Centers, Winter Haven, Florida
| | - Emily Poon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Otolaryngology- Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
2
|
Bacteriostatic preserved saline for pain-free periocular injections: review. Eye (Lond) 2022; 36:1546-1552. [PMID: 35017698 PMCID: PMC8749351 DOI: 10.1038/s41433-021-01925-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/20/2021] [Accepted: 12/22/2021] [Indexed: 11/26/2022] Open
Abstract
We review evidence regarding the use of 0.9% benzyl alcohol in 0.9% sodium chloride solution for periocular injections (‘preserved saline’) including botulinum toxin A injections and local anaesthesia. A literature search was undertaken using search terms ‘bacteriostatic saline’, ‘benzyl-alcohol saline’, ‘benzyl alcohol sodium chloride’ and ‘preserved saline’. Bibliographies identified further sources. There have been 62 studies published on the subject of preserved-saline since 1928. Significantly lower injection-associated pain levels for periocular/facial botulinum toxin injections reconstituted with preserved-saline rather than preservative-free saline are reported by 5 studies. Significantly lower injection-associated pain with preserved-saline diluted lidocaine and epinephrine solution for eyelid anaesthesia compared with unmodified or buffered lidocaine with epinephrine, and adequate anaesthesia, was reported by one study. Thirty-one studies have explored preserved-saline for anaesthetic and seven for bacteriostatic properties, with very low infection rates after periocular botulinum toxin injections, and reduced rates of infection in indwelling catheters when preserved saline is used to flush. A meta-analysis concluded that lidocaine-containing solutions are more effective at reducing pain from insertion of intravenous catheters. Patient-perceived pain related to periorbital injections of local anaesthesia is reduced when the anaesthetic is diluted with benzyl alcohol-preserved saline compared with other dilution or buffering options. Pain is similarly reduced for periocular botulinum toxin injections reconstituted with preserved saline compared with unpreserved saline. Benzyl-alcohol preserved-saline is inexpensive but costlier than unpreserved-saline, with minimal reported complications, particularly with periocular administration, and offers the opportunity to improve the patient experience.
Collapse
|
3
|
Zidan A, Hussaini S, Gibson S, Brooks G, Mejico L. Onabotulinumtoxin Type A reconstitution with preserved versus preservative-free saline in chronic migraine (B-RECON). A randomised, double-blind trial. Int J Clin Pract 2020; 74:e13522. [PMID: 32350975 DOI: 10.1111/ijcp.13522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/13/2020] [Accepted: 04/27/2020] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Onabotulinumtoxin type A (BoNTA) is manufactured as powder that requires reconstitution with normal saline prior to injection. Previous literature has suggested that preserved saline (PS) exerts a local anaesthetic effect, and reduces the procedure discomfort when used in reconstitution in lieu of preservative-free saline (PFS). However, this was mainly studied in the aesthetics indications of BoNTA, and never in its use for the treatment of chronic migraine. The distinction is important as chronic migraine population suffers high incidence of scalp allodynia which makes it more prone to injection site pain. In addition, the pain of the procedure itself may be related to the spike of migraine frequency in the immediate postprocedural period which can occur in up to 5% of patients receiving the treatment. Our trial aimed to study the difference in procedural pain scale, and postprocedural headache rating with the use of PS vs PFS in constitution of BoNTA when used as a treatment for chronic migraine. METHODS 68 subjects were consecutively enrolled in an outpatient setting at a large tertiary headache centre over a period of 6 months. Subjects were randomised into PS or PFS group. BoNTA was administered as per standard protocol in both groups. Injection site pain scores and frequency of headache days in the immediate following week were recorded. Wilcoxon rank sum tests were used to compare differences in between groups using SPSS software. RESULTS Analysis (SAS V 9.4) revealed that those receiving [PF] had significantly higher procedure pain scores than those receiving [P] (5.3 vs 3.2, respectively). There was no difference in the headache or migraine frequency in the immediate postprocedural period. CONCLUSION This study supports the use of PS (bacteriostatic) over PFS for reconstitution of BoNTA in chronic migraine as it reduces the discomfort of the injection sites.
Collapse
Affiliation(s)
- Awss Zidan
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Sharmeen Hussaini
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Sandra Gibson
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Gary Brooks
- Center for Research and Evaluation, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Luis Mejico
- Department of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
4
|
Giordano CN, Matarasso SL, Ozog DM. Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents. J Am Acad Dermatol 2017; 76:1013-1024. [PMID: 28522038 DOI: 10.1016/j.jaad.2016.11.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 11/03/2016] [Accepted: 11/06/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.
Collapse
Affiliation(s)
| | - Seth L Matarasso
- Department of Dermatology, University of California, San Francisco School of Medicine, San Francisco, California
| | - David M Ozog
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.
| |
Collapse
|
5
|
Prevention and Management of Injection-Related Adverse Effects in Facial Aesthetics: Considerations for ATX-101 (Deoxycholic Acid Injection) Treatment. Dermatol Surg 2016; 42 Suppl 1:S300-S304. [DOI: 10.1097/dss.0000000000000898] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
6
|
Dickey RM, Louis MR, Cox JA, Mohan K, Lee EI, Nigro MG. Noninvasive Facial Rejuvenation. Part 2: Physician-Directed-Neuromodulators and Fillers. Semin Plast Surg 2016; 30:134-42. [PMID: 27478422 DOI: 10.1055/s-0036-1584819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin as well as rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the second in a three-part series describing noninvasive facial rejuvenation. Here the authors discuss neuromodulators and fillers in detail, focusing on indications for use, techniques, and common side effects.
Collapse
Affiliation(s)
- Ryan M Dickey
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Matthew R Louis
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joshua A Cox
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Kriti Mohan
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Edward I Lee
- Division of Plastic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | | |
Collapse
|
7
|
Dressler D, Adib Saberi F, Bigalke H. Botulinum toxin therapy: reduction of injection site pain by pH normalisation. J Neural Transm (Vienna) 2016; 123:527-31. [PMID: 27002815 DOI: 10.1007/s00702-016-1522-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
Abstract
Botulinum toxin (BT) is injected intramuscularily and may produce injection site pain (ISP). We wanted to explore whether the pH value of the reconstituted BT drug contributes to ISP and, if so, what strategies can be applied to reduce it. In part 1 of the study, pH values of different reconstitution solutions and of major BT drugs reconstituted with different reconstitution solutions were assessed. In part 2, the effects of reconstitution with normal saline (NS) and Ringer acetate (RA) were compared intraindividually and in a double blind fashion in 34 patients with blepharospasm. pH values of reconstitution solutions were 5.52 ± 0.02 for NS, 6.98 for RA, 6.31 for Ringer lactate, 6.56 for electrolyte and 5.31 for bacteriostatic solution. pH values for NS-reconstitution were 6.09 ± 0.20 for Botox(®), 5.95 ± 0.24 for Dysport(®) and 5.81 ± 0.18 for Xeomin(®). pH values for RA-reconstitution were 6.95 ± 0.03 for Botox(®), 7.01 ± 0.02 for Dysport(®) and 6.87 ± 0.06 for Xeomin(®). By using RA instead of NS the pH could be increased by 0.86 for Botox(®), by 1.06 for Dysport(®) and by 1.06 for Xeomin(®). 47 % of the patients experienced less ISP when Botox(®)-RA was given rather than Botox(®)-NS, 76 % when Xeomin(®)-RA was given rather than Xeomin(®)-NS. None of the patients reported a difference in efficacy between NS- and RA-reconstitution. Despite previous reports, reconstituted BT type A drugs show acidic pH values. Normalising these pH values by use of RA instead of NS reduces ISP considerably without sacrificing clincial efficacy.
Collapse
Affiliation(s)
- Dirk Dressler
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Fereshte Adib Saberi
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Hans Bigalke
- Movement Disorders Section, Department of Neurology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Institute of Toxicology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| |
Collapse
|
8
|
Alam M, Bolotin D, Carruthers J, Hexsel D, Lawrence N, Minkis K, Ross EV. Consensus statement regarding storage and reuse of previously reconstituted neuromodulators. Dermatol Surg 2015; 41:321-6. [PMID: 25705950 DOI: 10.1097/dss.0000000000000303] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Legacy recommendations suggest that vials of botulinum toxin be used within 24 hours of reconstitution and in a single patient. Current standard of care is consistent with storage after reconstitution and use of a single vial for several patients. OBJECTIVE To develop expert consensus regarding the effectiveness and safety of storage and reuse of botulinum toxin. MATERIALS AND METHODS The American Society for Dermatologic Surgery authorized a task force of content experts to review the literature and provide guidance. Data extraction was followed by clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS After 2 rounds of Delphi process, the task force concluded by unanimous consensus and with the highest level of confidence that a vial of toxin reconstituted appropriately can, for facial muscle indications, be (1) refrigerated or refrozen for at least 4 weeks before injection without significant risk for contamination or decreased effectiveness and (2) used to treat multiple patients, assuming appropriate handling. CONCLUSION The standard of care, which allows for use of botulinum toxin more than 24 hours after reconstitution and in more than 1 patient per vial, is appropriate and consistent with the safe and effective practice of medicine.
Collapse
Affiliation(s)
- Murad Alam
- Departments of *Dermatology, †Otolaryngology, and ‡Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; §Section of Dermatology, University of Chicago Medicine, Chicago, Illinois; ‖Department of Ophthalmology, University of British Columbia, Vancouver, BC, Canada; ¶Department of Dermatology, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil; #Brazilian Center for Studies in Dermatology, Porto Alegre, Brazil; **Division of Dermatology, Cooper University Hospital Medical Center, Marlton, New Jersey; ††Department of Dermatology, Weill Cornell Medical College, Cornell University, New York, New York; ‡‡Division of Dermatology, Scripps Clinic, San Diego, California
| | | | | | | | | | | | | |
Collapse
|
9
|
Kakar R, Ibrahim O, Disphanurat W, Pace N, West DP, Kwasny M, Shah S, Alam M. Pain in Naïve and Non-naïve Subjects Undergoing Nonablative Skin Tightening Dermatologic Procedures: A Nested Randomized Control Trial. Dermatol Surg 2014; 40:398-404. [DOI: 10.1111/dsu.12440] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
10
|
Allen SB, Goldenberg NA. Pain difference associated with injection of abobotulinumtoxinA reconstituted with preserved saline and preservative-free saline: a prospective, randomized, side-by-side, double-blind study. Dermatol Surg 2012; 38:867-70. [PMID: 22268727 DOI: 10.1111/j.1524-4725.2011.02284.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Food and Drug Administration has approved the reconstitution of botulinum toxin A with preservative-free saline. Reconstitution of onabotulinumtoxinA with preserved saline has been previously reported to decrease the pain of injections. We present the first split-face study investigating differences in subjective pain when using preserved and preservative-free saline as the reconstituent of choice for abobotulinumtoxinA. OBJECTIVE To determine whether patients notice a difference in pain when injecting abobotulinumtoxinA diluted with preserved saline versus preservative-free saline. MATERIALS AND METHODS A prospective, randomized, double-blind, side-by-side trial was conducted in a private practice dermatology office in Boulder, Colorado. Twenty volunteer patients received injections on one side of their face with abobotulinumtoxinA reconstituted with preservative-free saline and with abobotulinumtoxinA reconstituted with preserved saline on the other side. Patients reported their pain on a 10-point visual analogue pain scale after each side was injected. Patients kept a diary for the first 48 hours after treatment to track any continued pain, onset of action, or adverse events. Patients were seen at a follow-up visit at 2 weeks, and any adverse events were recorded. RESULTS Ninety percent of patients reported less pain on the side injected with preserved saline than on the side injected with preservative-free saline. Pain on the preserved saline side was 60% less than on the preservative-free side. Neither the patients nor the investigators noted any difference in onset of action between the two sides. CONCLUSIONS Reconstitution of abobotulinumtoxinA with preserved saline results in significantly less pain on injection than with preservative-free saline. Preserved saline may be the reconstituent of choice for reconstitution of abobotulinumtoxinA.
Collapse
Affiliation(s)
- Shawn B Allen
- Department of Dermatology, School of Medicine, University of Colorado, Denver, Colorado, USA.
| | | |
Collapse
|
11
|
Kaynak-Hekimhan P. Noncosmetic periocular therapeutic applications of botulinum toxin. Middle East Afr J Ophthalmol 2011; 17:113-20. [PMID: 20616916 PMCID: PMC2892125 DOI: 10.4103/0974-9233.63069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Botulinum toxin blocks acetylcholine release at the neuromuscular junction. The drug which was initially found to be useful in the treatment of strabismus has been extremely effective in the treatment of variety of conditions, both cosmetic and noncosmetic. Some of the noncosmetic uses of botulinum toxin applications include treatment of spastic facial dystonias, temporary treatment of idiopathic or thyroid dysfunction-induced upper eyelid retraction, suppression of undesired hyperlacrimation, induction of temporary ptosis by chemodenervation in facial paralysis, and correction of lower eyelid spastic entropion. Additional periocular uses include control of synchronic eyelid and extraocular muscle movements after aberrant regeneration of cranial nerve palsies. Cosmetic effects of botulinum toxin were discovered accidentally during treatments of facial dystonias. Some of the emerging nonperiocular application for the drug includes treatment of hyperhidrosis, migraine, tension-type headaches, and paralytic spasticity. Some of the undesired side effects of periocular applications of botulinum toxin inlcude ecchymosis, rash, hematoma, headache, flu-like symptoms, nausea, dizziness, loss of facial expression, lower eyelid laxity, dermatochalasis, ectropion, epiphora, eyebrow and eyelid ptosis, lagophthalmos, keratitis sicca, and diplopia.
Collapse
|
12
|
[Prevention and management of locoregional complications of botulinum A toxin injections in cosmetic treatment]. Ann Dermatol Venereol 2009; 136 Suppl 4:S146-51. [PMID: 19576482 DOI: 10.1016/s0151-9638(09)74543-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Botulinum toxin serotype A injections used in treating dynamic wrinkles is one of the least invasive cosmetic procedures. High patient satisfaction and low onset of always moderate side effects contribute to the growing popularity of botulinum toxin injections in cosmetic treatment over the past few years. Years of experience and use, in therapeutics [1,2] and esthetics (20 years) have proven the efficacy and the safety of this wrinkle treatment. Today, no severe or long-term side effects have been reported in esthetics. This article discusses only the most frequent locoregional effects. They are rare, moderate, transitory, and totally reversible. Properly informing and selecting patients will contribute to successfully preventing and managing these effects.
Collapse
|
13
|
Abstract
Primary focal hyperhidrosis is a disorder of idiopathic excessive sweating that typically affects the axillae, palms, soles, and face. The disorder, which affects up to 2.8% of the US population, is associated with considerable physical, psychosocial, and occupational impairments. Current therapeutic strategies include topical aluminum salts, tap-water iontophoresis, oral anticholinergic agents, local surgical approaches, and sympathectomies. These treatments, however, have been limited by a relatively high incidence of adverse effects and complications. Non-surgical treatment complications are typically transient, whereas those of surgical therapies may be permanent and significant. Recently, considerable evidence suggests that botulinum toxin type A (BTX-A) injections into hyperhidrotic areas can considerably reduce focal sweating in multiple areas without major adverse effects. BTX-A has therefore shown promise as a potential replacement for more invasive treatments after topical aluminum salts have failed. This article reviews the epidemiology, diagnosis, and management of primary focal hyperhidrosis, with an emphasis on recent research evidence supporting the use of BTX-A injections for this indication.
Collapse
Affiliation(s)
- Alexander Grunfeld
- Faculty of Medicine, University of Toronto, Women's College Hospital, Toronto, Ontario, Canada
| | | | | |
Collapse
|
14
|
EMLA Cream Application Without Occlusive Dressing Before Upper Facial Botulinum Toxin Injection. Ann Plast Surg 2008; 60:353-6. [DOI: 10.1097/sap.0b013e31812f6e0f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
15
|
Adelson RT. Botulinum neurotoxins: fundamentals for the facial plastic surgeon. Am J Otolaryngol 2007; 28:260-6. [PMID: 17606044 DOI: 10.1016/j.amjoto.2006.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2006] [Accepted: 09/07/2006] [Indexed: 10/23/2022]
Abstract
The most commonly performed nonsurgical cosmetic procedure in the facial plastic surgery armamentarium involves the various commercial preparations of botulinum neurotoxins. These drugs have undergone a transformation from public health scourge to near ubiquitous therapeutic modality across the entire medical spectrum. Herein, the history of botulinum neurotoxins is reviewed, including an exploration of their pharmacology, neuromuscular junction physiology, a description of the commercially available preparations, and the recent research concerning the practicalities of their clinical use.
Collapse
Affiliation(s)
- Robert Todd Adelson
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Florida, PO Box 100264, Gainesville, FL 32610, USA.
| |
Collapse
|
16
|
Sami MS, Soparkar CNS, Patrinely JR, Hollier LM, Hollier LH. Efficacy of Botulinum Toxin Type A After Topical Anesthesia. Ophthalmic Plast Reconstr Surg 2006; 22:448-52. [PMID: 17117100 DOI: 10.1097/01.iop.0000248989.33572.3c] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine whether the use of topical anesthesia has an impact on botulinum toxin type A (BTX-A) efficacy. METHODS Forty patients (20 receiving BTX-A for facial cosmetic rhytid reduction and 20 for benign essential blepharospasm) were evaluated in a double-blind, randomized, triple-crossover study at 2.5- to 4.5-month intervals. The discomfort and efficacy of BTX-A injections after betacaine application to half the face (random assignment) were compared against the discomfort and efficacy of a placebo ointment on the other half of the face. This was followed by cryoanalgesia to the entire face. RESULTS Patients ranged from 27 to 81 years of age (mean, 53 years), and 34 were female. Of the 120 total injection comparisons, a better BTX-A effect on one side of the face was reliably identified by 80% and 77% of blepharospasm and cosmetic patients, respectively, with the placebo-treated side providing better BTX-A effect approximately 90% of the time (p < 0.001). Patients reported a more painful side during injection in just 18 of the 120 trials, and only 1 of 40 patients believed the administration of analgesia was worth the trouble. CONCLUSIONS Pretreatment with topical betacaine followed by skin cooling seems to have a deleterious impact on BTX-A effect without a significantly beneficial patient-perceived reduction in injection discomfort.
Collapse
Affiliation(s)
- Mirwat S Sami
- Plastic Eye Surgery Associates, PLLC, Houston, Texas, USA
| | | | | | | | | |
Collapse
|
17
|
Pain Sensation during Intradermal Injections of Three Different Botulinum Toxin Preparations in Different Doses and Dilutions. Dermatol Surg 2006. [DOI: 10.1097/00042728-200607000-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
18
|
Kranz G, Sycha T, Voller B, Gleiss A, Schnider P, Auff E. Pain Sensation during Intradermal Injections of Three Different Botulinum Toxin Preparations in Different Doses and Dilutions. Dermatol Surg 2006; 32:886-90. [PMID: 16875469 DOI: 10.1111/j.1524-4725.2006.32191.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pain sensation associated with injections of botulinum neurotoxin (BoNT) is commonly reported. To date differences in pain sensation between the commercially available products containing BoNT have not been quantified. OBJECTIVES The pain sensations during injection of Dysport, Botox, Neurobloc, and pure saline (control) were compared. In addition, the nociceptive effect of different volumes used for the dilution of the same BoNT dose was investigated. METHODS In a prospective, double-blind, controlled trial, 10 healthy subjects were injected intradermally with Dysport (12 U), Botox (3 and 4 U), Neurobloc (150 and 300 U) reconstituted in 0.9% saline, and pure saline. Pain sensation was quantified during injections. RESULTS Neurobloc injections caused significantly more injection pain than Botox, Dysport, and saline. No significant differences between Dysport, Botox, and saline were found, although there was a trend toward less pain with pure saline injections. Higher pain levels with higher volumes could not be demonstrated significantly. CONCLUSION Our data demonstrate that BoNT type B injections are associated with substantial pain. There is a considerable difference between the commercially available BoNT type B compared to the two BoNT type A preparations. Therefore, considering mitigation of injection pain seems necessary when using BoNT type B.
Collapse
Affiliation(s)
- Gottfried Kranz
- Department of Neurology, Division of Neurorehabilitation, Medical University of Vienna, Vienna, Austria.
| | | | | | | | | | | |
Collapse
|
19
|
Bhidayasiri R, Cardoso F, Truong DD. Botulinum toxin in blepharospasm and oromandibular dystonia: comparing different botulinum toxin preparations. Eur J Neurol 2006; 13 Suppl 1:21-9. [PMID: 16417594 DOI: 10.1111/j.1468-1331.2006.01441.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Amongst all regions of the body, the craniocervical region is the one most frequently affected by dystonia. Whilst blepharospasm--involuntary bilateral eye closure--is produced by spasmodic contractions of the orbicularis oculi muscles, oromandibular dystonia may cause jaw closure with trismus and bruxism, or involuntary jaw opening or deviation, interfering with speaking and chewing. Both forms of dystonia can be effectively treated with botulinum toxin injection. This article summarizes injection techniques in both forms of dystonia and compares doses, potency and efficacy of different commercially available toxins, including Botox, Dysport, Xeomin and Myobloc/NeuroBloc.
Collapse
Affiliation(s)
- R Bhidayasiri
- Division of Neurology, Chulalongkorn University Hospital, Bangkok, Thailand
| | | | | |
Collapse
|
20
|
Görgü M, Silistreli OK, Karantinaci B, Ayhan M, Ozdemirkiran T, Celebisoy M. Interaction of botulinum toxin type A with local anesthetic agents: an experimental study with rabbits. Aesthetic Plast Surg 2006; 30:59-64. [PMID: 16404653 DOI: 10.1007/s00266-004-0015-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Injection of botulinum toxin is a painful procedure, limiting the number of patients treated. This study was designed to establish whether infiltration of local anesthetics plays a role in the effectiveness of botulinum toxin. For the study, 24 New Zealand white rabbits were divided into three groups. In all three groups, local anesthetics (prilocaine, lidocaine, lidocaine, and epinephrine) were injected into the right anterior auricular muscle before a 2.5-U injection of botox A. The contralateral anterior auricular muscle of all the rabbits was injected with the same dose of the toxin to serve as a control. Photographic documentation was recorded; electromyographic study was performed; and results were statistically analyzed. The results show that local anesthetics do not play a role in the efficacy of botulinum toxin. Thus, the use of infiltrative local anesthetics before botulinum toxin injection is a safe method for achieving a less painful procedure for the patient.
Collapse
Affiliation(s)
- Metin Görgü
- Ataturk Training and Research Hospital, Izmir, Turkey
| | | | | | | | | | | |
Collapse
|
21
|
Affiliation(s)
- Geva E Mannor
- Eye Plastic and Orbit Surgery, Division of Ophthalmology, Scripps Clinic, 10666 North Torrey Pines Road (MS 313), La Jolla, CA 92037, USA
| |
Collapse
|
22
|
Sarifakioglu N, Sarifakioglu E. Evaluating effects of preservative-containing saline solution on pain perception during botulinum toxin type-a injections at different locations: a prospective, single-blinded, randomized controlled trial. Aesthetic Plast Surg 2005; 29:113-5. [PMID: 15815811 DOI: 10.1007/s00266-004-0062-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2004] [Accepted: 10/18/2004] [Indexed: 10/25/2022]
Abstract
Pain is a side effect of botulinum toxin type-A (BTX-A) injections. The efficiency of the preservative-containing saline solution used as the "dilution solution" for controlling the pain felt during multiple injections in different areas has been investigated by a prospective, randomized, single-blinded, controlled study. A total of 93 patients were divided into three groups for the study. All the patients were given BTX-A. Of these 93 patients, 60 received injections in the upper face, 15 in the neck, and 18 in the axillary regions. The visual analog scale (VAS), a single-dimension pain intensity rating scale, was used to evaluate pain perception. The average VAS values for pain sensation experienced by the groups were 1.2 of 10 points for the upper face area in the experimental group (n = 60) and 4.5 point for the control group. In the neck region (n = 15), the respective scores were 0.6 in the experimental group and 3.9 in the control group. Finally, in the axillary region (n = 18), the respective values were 0.9 and 5.1. The authors conclude that the preservative-containing saline solution significantly decreased pain perception during BTX-A injections (p = 0.000).
Collapse
Affiliation(s)
- Nedim Sarifakioglu
- Department of Plastic and Reconstructive Surgery, Fatih University School of Medicine, Ankara, Turkey.
| | | |
Collapse
|
23
|
Sarifakioglu N, Sarifakioglu E. Evaluating the Effects of Ice Application on the Pain Felt During Botulinum Toxin Type-A Injections. Ann Plast Surg 2004; 53:543-6. [PMID: 15602250 DOI: 10.1097/01.sap.0000139563.51598.75] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The pain felt during botulinum toxin type-A injections and the troubled and distressed treatment it induces is common and well known for the patient and the doctor applying the treatment. This problem is further intensified on the patients who have needle phobia. The effect of ice application on the treatment zone before botulinum toxin type-A treatment on the pain felt during injections is investigated. Totally, 24 patients who underwent botulinum toxin type-A treatment in upper face region for esthetic purposes are included in the study. Ice was applied 5 minutes before the injections on the right lateral orbital zones (crow's feet area) of the patients, whereas on their left sides, toxin was injected without applying any ice. All the drugs were diluted by normal saline; 5 U of active botulinum toxin type-A was used in each diziem (0.1 mL). Total injection number was determined both in right and left areas as 8. Visual analog scale (VAS) was used for pain intensity and evaluation. On the side where ice was applied, the treatment was completed in 1 session and lasted shorter when compared with that of the control side. However, the average VAS values defining the pain that the patients felt in their right and left sides were found as 1.1 and 5.9, respectively. The clinical findings obtained indicated that pain is significantly reduced on the side where ice is applied. The statistical significance of the test results were evaluated by Student's t test, and the difference between VAS values was found statistically significant (P = 0.000).
Collapse
Affiliation(s)
- Nedim Sarifakioglu
- Department of Plastic and Reconstructive Surgery, Fatih University School of Medicine, Ankara, Turkey.
| | | |
Collapse
|
24
|
Batniji RK, Falk AN. Update on botulinum toxin use in facial plastic and head and neck surgery. Curr Opin Otolaryngol Head Neck Surg 2004; 12:317-22. [PMID: 15252254 DOI: 10.1097/01.moo.0000131443.50445.53] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss current trends in the medicinal use of botulinum toxin in head and neck and facial plastic surgery. The basic science of botulinum toxin is presented along with a comparison of the subtypes currently available on the market. Site-specific applications of botulinum toxin in the head and neck region are presented. RECENT FINDINGS The use of botulinum toxin continues to expand, both in volume and in number of applications. The main application of botulinum toxin in facial plastic surgery is in the effacement of dynamic or hyperkinetic facial lines. The granting of US Food and Drug Administration approval for the use of Botulinum Toxin type A in the treatment of glabella lines marks a major milestone for the more widespread usage of this product in cosmetic settings. Additional cosmetic applications include crow's feet, marionette lines, and platysma banding. Noncosmetic applications in the head and neck include dystonias (including torticollis), facial and generalized muscle spasms, migraine headaches, hyperhidrosis, spasmodic dysphonia, sialorrhea, gustatory sweating, and involuntary movement disorders. SUMMARY The use of botulinum toxin in the treatment of hyperkinetic conditions and disorders of excessive salivation is well established and enjoys an excellent safety profile. The cosmetic use of botulinum toxin continues to expand. The chronic use of botulinum toxin specifically for cosmetic purposes is worthy of additional study.
Collapse
Affiliation(s)
- Rami K Batniji
- University Ear Nose and Throat of Northeastern New York, LLP & The Center for Facial Plastic Surgery and Division of Otolaryngology-Head and Neck Surgery, Albany Medical College, Albany, New York 12208-3479, USA
| | | |
Collapse
|