Peri-Incisional Botulinum Toxin Therapy for Treatment of Intractable Head Pain After Lateral Skull Base Surgery: A Case Series.

OBJECTIVE: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. BACKGROUND: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. METHODS: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. RESULTS: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. CONCLUSIONS: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.

Management of Nasal and Perinasal Soft Tissue Injuries.

The prominence of the nose renders it susceptible to soft tissue trauma of multiple etiologies. In this review, we present a framework for evaluation and treatment of nasal soft tissue injuries. Initial evaluation of nasal soft tissue injuries should include a complete trauma assessment, history, and physical examination. Mechanisms described include lacerations, abrasions, bites, and thermal injuries. Finally, we discuss wound care and surgical treatment options, including local flap and free tissue transfer. Though timing of repair remains somewhat controversial, most sources indicate that immediate reconstruction should be undertaken when possible.

Augmented Skin Grafting: A New Rung in the Reconstructive Ladder.

Importance: A gap in the reconstructive ladder exists in which complex defects may benefit from skin grafting but are not amenable due to their anatomic limitations. Similarly, some patients are intolerant of more invasive techniques in cosmetically sensitive areas. In these scenarios, augmented skin grafts may represent a unique alternative to traditional reconstructive options. Observations: This report is a clinical overview of skin grafting in complex nasal defects. We describe three types of augmented skin grafts, with examples of each. These include preliminarily augmented grafts with a dermal biomatrix, simultaneous augmentation with a perichondrocutaneous pseudo-composite graft, and delayed augmentation with staged structural grafting. Conclusions and Relevance: Augmented skin grafts represent unique methods of reconstruction for complex wounds in cosmetically sensitive areas. We propose these techniques as an evolving unique rung in the reconstructive ladder.