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Goldberg SH, Gehrman MD, Graham JH. Botulinum Toxin A and B Improve Perfusion, Increase Flap Survival, Cause Vasodilation, and Prevent Thrombosis: A Systematic Review and Meta-analysis of Controlled Animal Studies. Hand (N Y) 2023; 18:22-31. [PMID: 33645294 PMCID: PMC9806538 DOI: 10.1177/1558944721994250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND A systematic review and meta-analysis of case-control animal model studies will help clarify the vascular effects of botulinum toxin (BTX). METHODS Preferred Reporting Items of Systematic reviews and Meta-Analyses guidelines were used to identify all animal case-control studies published before September 13, 2020, evaluating the vascular effects of BTX. Primary parameters included the following: perfusion, flap survival, arterial and venous dilation, and arterial and venous thrombosis. RESULTS Thirty-six studies with 1032 animals met the systematic review inclusion criteria. Twenty-nine studies had quantifiable data for statistical analysis. Statistically significant increases in perfusion with BTX over saline were detected within 1 day and sustained up to 8 weeks. The following represent weighted mean data from the meta-analysis. The administration of BTX has a 26% increase in both random pattern and pedicled flap survival area over controls. Botulinum toxin causes vasodilation. Botulinum toxin increases vessel diameter in arteries by 40% and in veins by 46% compared with saline controls. The administration of BTX reduces thrombosis by 85% in arteries and by 79% in veins compared with saline controls. Vascular effects were consistent across both BTX-A and BTX-B serotypes, multiple animal species, and various doses. No clear relationships between vascular effects and BTX pretreatment time were identified. CONCLUSIONS Perivascular BTX administration intraoperatively or as a chemical delay pretreatment several days before surgery in multiple animal species and models shows multiple changes to the vascular system. Extrapolation of lessons learned from this systematic review and meta-analysis of animal models could expand research and clinical use of BTX in human vascular disease and surgery.
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Affiliation(s)
- Steven H. Goldberg
- Bellin Health Systems, Green Bay, WI,
USA
- Geisinger Medical Center, Danville, PA,
USA
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2
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Experimental study of the effects of nitroglycerin, botulinum toxin A, and clopidogrel on bipedicled superficial inferior epigastric artery flap survival. Sci Rep 2022; 12:20891. [PMID: 36463303 PMCID: PMC9719547 DOI: 10.1038/s41598-022-24898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/22/2022] [Indexed: 12/04/2022] Open
Abstract
Beneficial effects could be achieved by various agents such as nitroglycerin, botulinum toxin A (BoTA), and clopidogrel to improve skin flap ischaemia and venous congestion injuries. Eighty rats were subjected to either arterial ischaemia or venous congestion and applied to a bipedicled U-shaped superficial inferior epigastric artery (SIEA) flap with the administration of nitroglycerin, BoTA, or clopidogrel treatments. After 7 days, all rats were sacrificed for flap evaluation. Necrotic area percentage was significantly minimized in flaps treated with clopidogrel (24.49%) versus the ischemic flaps (34.78%); while nitroglycerin (19.22%) versus flaps with venous congestion (43.26%). With ischemia, light and electron microscopic assessments revealed that nitroglycerin produced degeneration of keratinocytes and disorganization of collagen fibers. At the same time, with clopidogrel administration, there was an improvement in the integrity of these structures. With venous congestion, nitroglycerin and BoTA treatments mitigated the epidermal and dermal injury; and clopidogrel caused coagulative necrosis. There was a significant increase in tissue gene expression and serum levels of vascular endothelial growth factor (VEGF) in ischemic flaps with BoTA and clopidogrel, nitroglycerin, and BoTA clopidogrel in flaps with venous congestion. With the 3 treatment agents, gene expression levels of tumor necrosis factor-α (TNF-α) were up-regulated in the flaps with ischemia and venous congestion. With all treatment modalities, its serum levels were significantly increased in flaps with venous congestion and significantly decreased in ischemic flaps. Our analyses suggest that the best treatment option for ischemic flaps is clopidogrel, while for flaps with venous congestion are nitroglycerin and BoTA.
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Shi S, Jin R, Huang C, Zhou J. Effect of botulinum toxin type A on flap surgery in animal models: a systematic review and meta-analysis. J Plast Surg Hand Surg 2021; 56:198-207. [PMID: 34338133 DOI: 10.1080/2000656x.2021.1953044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Flaps are common technical choices in aesthetic and reconstructive surgeries. However, the poor flap survival rate remains to be a difficult issue that troubles plastic surgeon. Recent research evidence supports that the use of Botulinum toxin type A (BTXA) can increase the flap survival rate. For verification, the present study was carried out to evaluate the effect of BTXA on flap surgery. Eight databases (PubMed, Cochrane Library, Ovid, Web of Science, Embase, Scopus, CBM, CNKI and WANFANG database) were searched for related published literature up to September 2020. A meta-analysis was then conducted to compare the effect of using BTXA with that of using saline or no treatment in flap surgery. Seventeen studies with a total of 565 animals were finally included in this review after strict exclusion and inclusion. Compared with saline/no treatment + flap group, BTXA + flap group showed a significantly higher flap tissue survival rate (mean difference [MD] 15.55, p < 0.00001), blood flow (standardized mean difference [SMD] 1.97, p < 0.00001) and vascular endothelial growth factor (VEGF) expression (at mRNA level: SMD 6.01, p = 0.02; at protein level: SMD 3.35, p < 0.00001). BTXA combined with flap surgery may have a positive effect on improving the flap tissue survival rate, blood flow of flaps and VEGF expression. Besides, the timing of BTXA injection may be an important factor for exerting its effect on flap surgery.
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Affiliation(s)
- Shupeng Shi
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ruiqi Jin
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chengyu Huang
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Jianda Zhou
- Department of Plastic Surgery, The Third Xiangya Hospital, Central South University, Changsha, China
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Hassan AM, Chappell AG, Boyd RM, Joshi C, Wan R, Carabano M, Bai J, Patel A, Ullrich P, Ellis MF, Galiano RD. The Use of Botulinum Toxin to Prevent Anastomotic Thrombosis and Promote Flap Survival: A Bridge to Developing Clinical Studies. Ann Plast Surg 2021; 87:222-229. [PMID: 33470625 DOI: 10.1097/sap.0000000000002666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the possibility of using botulinum toxin to improve perfusion and prevent vasospasm, only a few studies have examined the use of botulinum toxin in the setting of flap surgery and thrombosis, and the mechanisms have not been fully explained. OBJECTIVE The primary objective of this study was to provide a comprehensive review of the effectiveness of botulinum toxin in anastomotic thrombosis prevention and surgical flap survival to determine the value of conducting large-scale human trials. METHODS Using the SYRCLE and CAMRADES criteria, a systematic review was performed. PubMed, Medline, EmBase, and the Cochrane Library were searched for studies that met our eligibility criteria. RESULTS Twenty studies were included in the final selection. A total of 397 subjects were included. Eighteen studies used botulinum toxin type A alone, one used botulinum toxin type B alone, and only one used both botulinum toxin type A and botulinum toxin type B. The most commonly used injection technique was a preoperative intradermal injection. The most common procedure performed was a pedicled flap with random pattern skin flaps (65%). The mean injection dose was 28.17 ± 49.21 IU, whereas the mean reported injection time for studies using animal models was 7.4 ± 6.84 days. CONCLUSIONS Similar mechanisms demonstrated in animal models may be replicable in humans, allowing botulinum toxin to be used to prolong flap survival. However, many factors, such as optimal injection techniques, dosages, and long-term outcomes of botulinum use in flap surgery, need to be further assessed before applying this to clinical practice.
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Affiliation(s)
- Abbas M Hassan
- From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Erdem M, Tiftikcioglu Y, Tatar BE, Kılıc KD, Uyanıkgil Y, Gürler T. The Effect of Botulinum Toxin on Flap Viability of the Posterior Thigh Perforator Flap in Rats. J Surg Res 2021; 261:85-94. [PMID: 33422903 DOI: 10.1016/j.jss.2020.12.025] [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: 05/25/2020] [Revised: 10/19/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The use of perforator propeller flaps in lower limb reconstruction has increased recently. Many pharmacological agents are used to increase flap viability. Botulinum toxin has been used in various types of flaps in the literature. However, there is no study regarding the use of botulinum toxin in the lower limb propeller flaps. This study investigates the effect of botulinum toxin administration on flap survival for lower limb propeller flap in rats. MATERIALS AND METHODS The study included 20 male Wistar albino rats, divided into two groups with a flap rotation of 90° in group 1 and 180° in group 2. In both groups, botulinum toxin was administered to the right thigh and a physiological saline solution was applied to the left thigh. Five days later, flaps were elevated over the posterior aspect of the right and left thighs and inset after 90° and 180° rotation was performed. Histopathological, immunohistochemical, and necrosis area analyses were performed. RESULTS Necrosis area, edema, polymorphonuclear leukocyte infiltration, and necrosis were found to be higher on the left side of the groups, whereas epidermal thickness, collagen density, vascularization, and hair root density were found to be higher on the right side of the groups. No significant difference was found between the right posterior thighs in either group on any parameter other than vascularization. Histopathologically and immunochemically statistically significant differences were found between the two groups. CONCLUSIONS The present study found that botulinum toxin increases flap viability in lower limb perforator-based propeller flaps.
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Affiliation(s)
- Mehmet Erdem
- Department of Plastic Surgery, University of Health Sciences, Bagcılar Training and Research Hospital, Istanbul, Turkey.
| | - Yigit Tiftikcioglu
- Department of Plastic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Burak Ergün Tatar
- Department of Plastic Surgery, University of Health Sciences, Bagcılar Training and Research Hospital, Istanbul, Turkey
| | - Kubilay Dogan Kılıc
- Department of Histology and Embryology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yigit Uyanıkgil
- Department of Histology and Embryology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Tahir Gürler
- Department of Plastic Surgery, Ege University Faculty of Medicine, Izmir, Turkey
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6
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Visualizing the Pharmacologic Preconditioning Effect of Botulinum Toxin Type A by Infrared Thermography in a Rat Pedicled Perforator Island Flap Model. Plast Reconstr Surg 2019; 144:1016e-1024e. [DOI: 10.1097/prs.0000000000006251] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Effect of Perivascular Injection of Botulinum Toxin Type A versus Lidocaine in Survival of Random Pattern Flaps in a Rat Model. Plast Reconstr Surg 2019; 143:527e-533e. [PMID: 30817649 DOI: 10.1097/prs.0000000000005337] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Botulinum toxin type A has gained popularity in many clinical fields, for a variety of aesthetic and therapeutic purposes. In addition, there have been reports regarding the positive effect of botulinum toxin type A on flap survival by various mechanisms. This study examines the role of botulinum toxin type A and lidocaine in augmentation of flap survival and decreasing the rate of necrosis in random pattern cutaneous flaps. METHODS In 45 male Sprague-Dawley rats, random pattern skin flaps with different width-to-length ratios were elevated. Botulinum toxin type A, lidocaine, or saline was administered to the base and whole length of the flap. Flap survival was evaluated on day 10 after surgery. The area of flap survival was determined grossly on the basis of its appearance, color, and texture. RESULTS The botulinum toxin type A group had a greater survival area (p < 0.05) compared with the lidocaine or saline group in flaps with width-to-length ratios of 1:2 and 1:3; however, compared with a width-to-length ratio of 1:1, the flap survival rate shows no statistically significant variations. CONCLUSION Injection of botulinum toxin type A in random pattern skin flaps improves tissue perfusion and increases the rate of flap survival more than lidocaine in flaps with width-to-length ratios of 1:2 and 1:3.
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Segreto F, Marangi GF, Signoretti M, Cazzato V, Giorgino R, Alessandri-Bonetti M, Persichetti P. The Use of Botulinum Toxin in Flap Surgery: A Review of the Literature. Surg Innov 2019; 26:478-484. [PMID: 30734634 DOI: 10.1177/1553350619828902] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Botulinum neurotoxin-A and botulinum neurotoxin-B have been shown to play a potential role in improving flap survival in animal models. The aim of this study is to review indications as well as to study injection timing, technique, and doses of botulinum neurotoxin-A and botulinum neurotoxin-B in animal models. Seventeen articles describe a total of 266 animals that underwent botulinum toxin injections before or during flap harvesting or vascular anastomosis procedure. All the studies demonstrated a beneficial effect of botulinum toxin administration in flap surgery or vascular anastomosis. Botulinum neurotoxin-A injection was shown to be a reliable approach in reducing vascular complications rate and increasing survival of flaps in animal models. The main conclusions drawn from the study include the following: perivascular injections targeting each vascular pedicle are preferred in cases of free flaps or axial flaps; subdermal injections are favorable in cases of random pattern skin flaps; and injections should be performed 7 days before flap elevation.
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Affiliation(s)
| | | | | | - Vito Cazzato
- 1 "Campus Bio-Medico di Roma" University, Rome, Italy
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Ravina K, Strickland BA, Rennert RC, Carey JN, Russin JJ. Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge. Neurosurg Focus 2019; 46:E13. [PMID: 30717063 DOI: 10.3171/2018.11.focus18514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/07/2018] [Indexed: 11/06/2022]
Abstract
Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.
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Affiliation(s)
| | | | - Robert C Rennert
- 4Department of Neurosurgery, University of California, San Diego, California
| | - Joseph N Carey
- 3Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
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Shi Y, Lin H, Cao J, Cui C. Botulinum toxin type A induces protective autophagy in human dermal microvascular endothelial cells exposed to an in vitro model of ischemia/reperfusion injury. Exp Ther Med 2018; 16:4379-4386. [PMID: 30542387 PMCID: PMC6257827 DOI: 10.3892/etm.2018.6741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 06/29/2018] [Indexed: 11/10/2022] Open
Abstract
Botulinum toxin type A (BTXA) has been reported to increase the survival of ischemic skin flaps; however, the exact mechanism underlying this effect remains unclear and needs to be further established. The present study aimed to elucidate whether autophagy caused by BTXA functions as a protection mechanism and to identify the mechanisms of its regulation by BTXA in human dermal microvascular endothelial cells (HDMECs) subjected to hypoxia/reoxygenation (H/R)-induced injury. HDMECs were harvested from the upper eyelid tissues of female blepharoplasty patients. HDMECs were exposed to BTXA treatment for 12 h and then subjected to hypoxia for 8 h, followed by reoxygenation for 24 h. Chloroquine diphosphate salt (CQ) was used as an autophagy inhibitor. H/R led to extreme injury to the HDMECs as indicated by the rise in the apoptosis rate, which was significantly attenuated by BTXA pretreatment. The outcomes demonstrated that H/R caused autophagy, as evidenced by a higher type II/type I ratio of light chain 3 (LC3), increased expression of Beclin-1 and increased autophagosome formation. BTXA enhanced autophagy and attenuated apoptosis in a dose-dependent manner, whereas CQ attenuated the BTXA antiapoptotic effects and inhibited the formation of autophagolysosomes, which caused clustering of the LC3-II in cells. In conclusion, autophagy promoted by BTXA serves as a potential protective effect on ischemia/reperfusion injury.
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Affiliation(s)
- Yanyu Shi
- Department of Plastic and Reconstructive Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Huang Lin
- Department of Plastic and Reconstructive Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Jiankun Cao
- Department of Plastic and Reconstructive Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
| | - Chao Cui
- Department of Plastic and Reconstructive Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P.R. China
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