Botulinum toxin type A (BOTOX) for treatment of migraine.

An open-label study and 2 double-blind, placebo-controlled studies have provided supporting evidence of botulinum toxin type A (BTX-A) as an effective, well-tolerated treatment for migraine. Observed durations of benefit were consistent with known properties of BTX-A. Findings suggest that response may vary by features of preinjection headaches, such as migraine frequency. The precise mechanism by which BTX-A provides pain relief is hypothesized to be related not only to acetylcholine inhibition but also to a blocking action on the parasympathetic nervous system. Additional studies that control factors likely to be related to response may lead to better understanding of the BTX-A effect on migraine and an optimal treatment protocol.

Current practices in the use of botulinum toxin A in the management of facial lines and wrinkles.

Botulinum toxin A (BTX-A) is a potent neurotoxin produced by the bacterium Clostridium botulinum. There are eight antigenically distinct serotypes, and they share a similar structure--a light chain with an associated molecule of zinc and a heavy chain linked by a disulfide bond. Each serotype has a separate site of action within the nerve ending. Only serotype A (Botox, Allergan, Irvine, CA) is available for clinical use in the United States.

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.

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.

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

OBJECTIVE: To determine the optimum dose and efficacy of botulinum toxin injections in the management of hyperfunctional facial lines. DESIGN: This study included 210 hyperfunctional facial sites in 162 different patients. The patients had preinjection and postinjection photographic documentation and ratings on a 4-point qualitative evaluation scale of lines at rest and with action. The patients then had botulinum toxin type A injections via a monopolar hollow bore, Teflon-coated electromyographic needle into the facial muscles associated with the hyperfunctional lines. The total dose for each region of 1.25 to 25 U was divided into 1.25- to 5-U aliquots representing 0.1 to 0.2 mL per injection site, depending on the site and the prior experience with that patient on using toxin. The patients had their reevaluation at 2 to 3 weeks after injection. Patients returned for further follow-up when the therapeutic effect diminished. PATIENTS: One hundred sixty-two patients had 210 hyperfunctional sites evaluated and injected. The group consisted of 25 male patients and 137 female patients ranging in age from 21 to 78 years with a mean (+/-SD) of 46.1 (+/-1.98) years. All patients had cosmetically troubling hyperfunctional lines involving the forehead, glabella, crow's feet (lateral canthal lines), nasolabial area, platysma, and mentalis region. RESULTS: All patients had an effect of toxin within the first 24 to 72 hours. Ninety-five percent of the patients treated had cosmetic improvement of unsightly facial lines or contractions. The best results were achieved in management of the forehead lines, followed by glabella, crow's feet, and nasolabial. The dose for forehead lines was 5 to 25 U (mean +/- SD, 17.3 +/- 6.2 U); glabellar lines, 5 to 20 U (mean +/- SD, 11.1 +/- 3.1 U); crow's feet, 5 to 15 U (mean +/- SD, 6.2 +/- 1.6 U); nasolabial, 2.5 to 5 U (mean +/- SD, 3.12 +/- 1.2 U); and platysma, 10 to 20 (mean +/- SD, 15 +/- 4.0 U). Evaluation by age and site suggested a trend of increased toxin dose with increased age. Effects of the toxin are usually seen 24 to 72 hours after injection, and last from 3 to 6 months, whereon the increased muscular activity returns, as do the hyperfunctional lines. The only morbidity was related to temporary mild weakness of other adjacent facial muscles. There were no systemic side effects noted. CONCLUSION: Botulinum toxin is a safe and important adjunctive technique for the management of patients with symptomatic hyperfunctional facial lines.

Reconstruction of posttraumatic and congenital facial deformities with three-dimensional computer-assisted custom-designed implants.

The principles, method, and benefits of combining three-dimensional computed tomography (CT) and computer-aided design/computer-aided manufacture (CAD/CAM) technology for development of custom-designed prostheses are applied in the repair of posttraumatic and congenital facial contour deficiencies. Each prosthesis is generated to fit the bone defect exactly, with external contours adjusted to compensate for overlying soft-tissue disparities. Three representative case reports from a series of 17 demonstrate the applications and advantages of using this technique. Some patients had residual defects after primary repair of posttraumatic deformities. Others had defects after orthognathic relapses for congenital deformities. Without a relatively minor surgery and a high degree of predictability, many of these patients would not have pursued further treatment. All but one of the surgeries were performed on an outpatient basis, providing an accurate, simple, and cost-effective method of contour restoration with limited morbidity and reduced operative time.

Submalar augmentation: a procedure to enhance rhytidectomy.

The use of submalar augmentation in facial rejuvenation surgery satisfies the need for enhancement of the midface to obtain longer lasting and better results from rhytidectomy. Submalar augmentation is a new surgical technique that positions anatomically designed silicone implants over the midthird of the face. It provides the appearance of restoring midfacial soft tissue and reduces the depth of anterior facial folds. The enhanced underlying bone structure avoids exerting excessive tension on the skin during face-lift surgery, thus preventing distortion of midfacial architecture. Submalar augmentation is a procedure that has been used as a supplementary enhancement to rhytidectomy in 56 patients over six and one-half years. Only minimal complications have been reported, all of which have been satisfactorily resolved. To date, no implant has been rejected or permanently removed. In our experience, when performed in conjunction with rhytidectomy, submalar augmentation has greatly enhanced and prolonged the results of face-lift surgery, and has significantly increased patient satisfaction.

Submalar augmentation. An alternative to face-lift surgery.

Submalar augmentation is a new approach that effectively deals with many of the problems encountered in midfacial rejuvenation. This study reports the results of 78 patients who were successfully treated over 6 years by submalar augmentation. This procedure consists of inserting newly designed Silastic (silicone rubber) implants over the midface to create the appearance of restoring the vibrant and youthful fullness of the middle third of the face while avoiding distortion of normal facial anatomy. When used alone, it provides an alternative to rhytidectomy in the 38- to 50-year age group. The benefits of submalar augmentation are such that it should be considered a standard part of the surgical approach to facial rejuvenation.

Mentoplasty--a clinical analysis of alloplastic implants.

Different types of alloplastic implants are currently being utilized in performing mentoplasty. A review of the literature points out the number of prostheses that have been used. Each type of material has inherit physical properties which determine its characteristics for use as a chin implant. The type of implant and method selected in chin augmentation depends upon accurate preoperative evaluation and full understanding of the properties of alloplastic substances. Five hundred and thirty-nine cases of chin augmentation utilizing different materials and methods were reviewed over a nine year period. The limitations of mentoplasty as well as the advantages, disadvantages, and in selected cases, the indications for the use of a particular implant are discussed.

Pseudomonas infection of the nose.

We report an unusual complication of nasal surgery. A rare, localized Pseudomonas infection of the nose developed after a routine submucous resection and nasal reconstruction in a healthy 56-year-old woman. We emphasize the need for early aggressive management in the treatment of Pseudomonas infections of the nose.

Iceberg of the nose.

Often in rhinoplasty, adequate osteotomies and mobilization of the nasal bones fail to close the dorsum--leaving an open roof deformity. Preexisting conditions and certain anatomical relationships contribute to this problem. The various methods of correcting the deformity are discussed and the author's approach presented.

Mucoepidermoid carcinoma of the larynx. A case report and review of the literature.

A case report of mucoepidermoid carcinoma of the larynx is presented and the literature reviewed. The inherent difficulties in histologic diagnosis are noted and the clinical behavior and treatment of mucoepidermoid carcinoma are discussed. At the present time, mucoepidermoid carcinoma of the larynx should be regarded as a separate entity, its treatment based on histological grade as well as clinical behavior.

A maneuver to improve the nasal airway.

The functional sequelae of rhinoplastic surgery are emphasized and the functional and anatomical causes of postoperative nasal obstruction are discussed. A maneuver to improve the airway and decrease the incidence of postoperative nasal obstruction is presented.

Tympanic neurectomy and chorda tympanectomy for the control of drooling.

Seventeen patients suffered from drooling that either occurred as a sequelae of extensive head and neck cancer resections or was due to neurological disorders. In these patients, a tympanic neurectomy and/or chorda tympanectomy was performed in an attempt to eliminate the drooling. The conditions in five of 12 (41%) patients with head and neck cancer were improved following such surgery. Two of four children with cerebral palsy initially had a good result. However, the long-term follow-up of the patients demonstrated that the drooling recurred. An additional patient suffering from bulbar weakness and drooling owing to a cerevrobascular accident had less problems with salivary secretions. The results were relatively disappointing; there are several possible explanations for this.

Evaluation of tympanic neurectomy and chorda tympanectomy surgery.

Thirty patients were treated by tympanic neurectomy, chorda tympanectomy, or both for a variety of conditions. Out of six patients with gustatory sweating treated by tympanic neurectomy, two patients were relieved of symptoms, two were improved, and two remained unchanged. In five cases of benign recurrent painful parotid swelling, only two patients noted improvement in symptoms. Seventeen patients suffered from drooling. Out of 12 postresection head and neck patients, 5 (41%) were improved following such surgery. Two of four cerebral palsy children initially had a good result. However, the long term follow-up of the patients demonstrated that the drooling recurred. An additional patient who suffered from drooling caused by bulbar weakness following a cerebrovascular accident had fewer problems with salivary secretions postoperatively. The pertinent anatomy and pathophysiology is outlined. The possible reasons for the relatively disappointing results achieved are discussed.