Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates

Personal Technique of Microinfiltration With Botulin Toxin: The SINB Technique (Superficial Injection Needling Botulinum)

The superficial injection needling botulinum (SINB) technique is the dermal injection of microdoses of botulin toxin, not by traditional syringe but with needling technique that consists in multiple microdroplets by electrical device. The intention is to decrease sweat and sebaceous gland activity to improve skin texture and sheen and to target the superficial layer of muscles that find attachment to the undersurface of the dermis causing visible rhytides. The technique is for treatment of face and neck by the injection of the botulin toxin into the dermis or in subdermal plane to improve skin texture, smoothen horizontal creases, and decrease vertical banding of the neck as well as to achieve better apposition of the platysma to the jawline and neck, improving contouring of the cervicomental angle. The botox solution is hyperconcentrated when compared to traditional dilution or compared to microbotox or mesobotox. Furthermore, the injection technique is different because spreading superficial microdroplets are not performed, but small, homogeneous, and controlled amounts of solution are injected. Each 0.8-mL syringe contains 50 units of onabotulinumtoxinA. The solution is delivered intradermally, using an electrical needling pen and setting the depth penetration of the needles at 3 to 3.5 mm. The 2 conjugated techniques play a 2-fold action on the skin. The technique was applied to a group of 63 patients dealing with face, forehead, cheekbones, and neck.

An Algorithm Using Botox Injections for Facial Scar Improvement in Fitzpatrick Type IV-VI Skin

BACKGROUND

Wounds of the face are known to heal poorly with conspicuous scarring. Hence, it is crucial to address the distracting effect of muscle pull on immature collagen, which often leads to worsening of scars.

STUDY DESIGN

Prospective clinical study.

METHODS

One hundred patients with a minimum of 6 months follow-up were recruited. All patients with depressed scars underwent surgery for scar revision. Two weeks before surgical intervention, intramuscular Botulinum toxin was injected around the scar, to prevent movement of the facial muscles. From the second week postsurgery, Cicatrix (Formulation containing activated Centella Asiatica & Pinus Sylvestris, Catalysis, Spain) was routinely used, 3 times a day, for 6 months post the scar revision surgery. Six weeks postsurgery, Fractional C02 laser treatment was started and performed every 4 weeks.

RESULTS

Using the Objective Assessment Score and the Subjective Assessment Score, the mean of the scores were taken. All patients had satisfactory results, as measured by a patient satisfaction survey and objectively by the physician assessment.

DISCUSSION

Botulinum toxin injected before scar revision surgery resulted in the wound being stabilized, better wound healing, and prevention of wound widening during healing.

CONCLUSION

In view of the results of this study, it is considered worthwhile to offer patients with facial scars, Botulinum toxin injections before scar revision surgery, followed by Fractional C02 laser, along with the routine use of Cicatrix Cream.

The application of W-plasty combined Botox-A injection in treating sunk scar on the face

This study was aimed to explore the effect of W-plasty combined Botox-A injection in improving appearance of scar.According to the inclusive and exclusive criteria, patients received W-plasty combined Botox-A injection (study group) or traditional (control group) scar repairment were enrolled in this study. After surgery, a follow-up ranged from 1 to 2 years was conducted. The effectiveness of surgery was assessed by visual analogue scale (VAS).A total of 38 patients were enrolled in this study, including 21 cases in the study group and 17 cases in the control group. There were no significant difference were identified in age (t = 0.339, P = .736), gender ratio (χ = 0.003, P = .955) and scar forming reason (χ = 0.391, P = .822) between 2 groups. After treatment, the VAS score in the study group was significantly higher than that in the control group (P < .001).W-plasty combined Botox-A injection can significantly improve the appearance of sunk scar on the face.

The Efficacy and Safety of Early Postoperative Botulinum Toxin A Injection for Facial Scars

BACKGROUND

Scars widen when the underlying musculature pulls apart suture lines, and scars oriented against relaxed skin tension lines are especially susceptible to these distraction forces. Because botulinum toxin A (BTA) induces complete muscle paralysis, the purpose of the current study was to evaluate the effects of BTA using both observer-dependent qualitative assessments and quantitative measurements to verify its beneficial effects on facial scarring.

METHODS

Patients with vertical forehead lacerations, treated by primary closure, were randomly assigned to two groups: one (n = 15) received BTA injections within 5 days of primary closure and the other (n = 15) received no further treatment. Vancouver scar scale (VSS) scores and wound width were determined at the 1-month and 6-month follow-up visits. Quantitative color differences between the scar and surrounding normal skin, using the Commission International d'Eclairage L*a*b* color coordinates, were measured and compared by analyzing photographs.

RESULT

Improved VSS scores, less increase in wound width, and less scar discoloration were noted among patients treated with BTA injections compared with the control group. These differences were observed at the 6-month visit, but not at the 1-month visit.

CONCLUSION

BTA injection improves scar quality when injected during the early postoperative days.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Antipruritic Effects of Botulinum Neurotoxins

This review explores current evidence to demonstrate that botulinum neurotoxins (BoNTs) exert antipruritic effects. Both experimental and clinical conditions in which botulinum neurotoxins have been applied for pruritus relief will be presented and significant findings will be highlighted. Potential mechanisms underlying antipruritic effects will also be discussed and ongoing challenges and unmet needs will be addressed.

Recent Understandings of Biology, Prophylaxis and Treatment Strategies for Hypertrophic Scars and Keloids

Hypertrophic scars and keloids are fibroproliferative disorders that may arise after any deep cutaneous injury caused by trauma, burns, surgery, etc. Hypertrophic scars and keloids are cosmetically problematic, and in combination with functional problems such as contractures and subjective symptoms including pruritus, these significantly affect patients’ quality of life. There have been many studies on hypertrophic scars and keloids; but the mechanisms underlying scar formation have not yet been well established, and prophylactic and treatment strategies remain unsatisfactory. In this review, the authors introduce and summarize classical concepts surrounding wound healing and review recent understandings of the biology, prevention and treatment strategies for hypertrophic scars and keloids.

Cutaneous Scarring: Basic Science, Current Treatments, and Future Directions

Significance: Scarring of the skin from burns, surgery, and injury constitutes a major burden on the healthcare system. Patients affected by major scars, particularly children, suffer from long-term functional and psychological problems. Recent Advances: Scarring in humans is the end result of the wound healing process, which has evolved to rapidly repair injuries. Wound healing and scar formation are well described on the cellular and molecular levels, but truly effective molecular or cell-based antiscarring treatments still do not exist. Recent discoveries have clarified the role of skin stem cells and fibroblasts in the regeneration of injuries and formation of scar. Critical Issues: It will be important to show that new advances in the stem cell and fibroblast biology of scarring can be translated into therapies that prevent and reduce scarring in humans without major side effects. Future Directions: Novel therapies involving the use of purified human cells as well as agents that target specific cells and modulate the immune response to injury are currently undergoing testing. In the basic science realm, researchers continue to refine our understanding of the role that particular cell types play in the development of scar.

Comparison of Steroid and Botulinum Toxin Type A Monotherapy with Combination Therapy for Treating Human Hypertrophic Scars in an Animal Model

BACKGROUND

The authors evaluated the efficacy of a combined regimen of botulinum toxin type A (Botox) and a steroid (triamcinolone acetonide) for treating hypertrophic scars in comparison with the treatment with each drug alone.

METHODS

Twenty excised human hypertrophic scar fragments obtained from surgically treated burn patients were divided into four groups: negative control (group A), triamcinolone alone (group B), Botox alone (group C), and a combination of triamcinolone and Botox (group D). These specimens were implanted into the backs of nude mice after intralesional injection from each group and were observed for 4 weeks. In total, 12 mice and 48 scars were studied. After 4 weeks, the hypertrophic scars were removed from the backs. The authors compared the scar weights, decorin staining, and the Cell Counting Kit-8 assay to evaluate treatment efficacy.

RESULTS

Significant differences in scar weight reduction were observed among the four groups (group A, 10 percent; group B, 17 percent; group C, 23 percent; and group D, 30 percent; p < 0.05). Treatment groups (groups B, C, and D) showed strong decorin staining. Significant differences in reduction of fibroblast proliferation were observed among the four groups (group A, 0.58; group B, 0.44; group C, 0.21; and group D, 0.08; p < 0.05). Botox or triamcinolone intralesional monotherapy showed significant therapeutic efficacy compared with the control group. The combined therapy further exhibited a significant therapeutic effect compared with monotherapy.

CONCLUSION

This study indicates the potential of Botox and triamcinolone when combined for intralesional therapy in treating hypertrophic scars.

Effect of BTXA on Inhibiting Hypertrophic Scar Formation in a Rabbit Ear Model

BACKGROUND

Hypertrophic scar (HS) is a refractory skin disease caused by major physical damage or other inflammation. Some reports found that botulinum toxin type A (BTXA) could be an alternative treatment of the HS. Therefore, the authors studied the effects of BTXA on the treatment of HS and the dose response of BTXA.

METHODS

Hypertrophic scars were harvested from the ears of 18 young adult New Zealand big-eared rabbits and treated with BTXA or triamcinolone acetonide (TAC) in vivo experiment. The hypertrophic index (HI) was measured by histological examination. Collagen fibrils were checked by sirius red straining, and the cell nucleuses of fibroblasts were checked by Ki67.

RESULTS

The HI of hypertrophic scars with BTXA treatment was lower than that with phosphate-buffered saline treatment (P < 0.05). Compared with the TAC treatment group, the efficacy of treatment with the middle dose of BTXA (1.0, 1.5 IU) had no significant difference, as shown by sirius red staining and immunohistochemistry Ki67.

CONCLUSION

These results demonstrated that BTXA effectively improved the appearance of hypertrophic scars and inhibited the formation of collagen fibrils and fibroblasts in vivo. Treatment with the middle dose of BTXA achieved similar efficacy as TAC treatment, indicating that BTXA might be useful for inhibiting hypertrophic scars and worth investigating further.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effect of Botulinum Toxin Type A on TGF-β/Smad Pathway Signaling: Implications for Silicone-Induced Capsule Formation

BACKGROUND

One of the most serious complications of breast surgery using implants is capsular contracture. Several preventive treatments have been introduced; however, the mechanism of capsule formation has not been resolved completely. The authors previously identified negative effects of botulinum toxin type A on capsule formation, expression of transforming growth factor (TGF)-β1, and differentiation of fibroblasts into myofibroblasts. Thus, the authors investigated how to prevent capsule formation by using botulinum toxin type A, particularly by means of TGF-β1 signaling, in human fibroblasts.

METHODS

In vitro, cultured human fibroblasts were treated with TGF-β1 and/or botulinum toxin type A. Expression of collagen, matrix metalloproteinase, and Smad was examined by Western blotting. The activation of matrix metalloproteinase was observed by gelatin zymography. In vivo, the effect of botulinum toxin type A on the phosphorylation of Smad2 in silicone-induced capsule formation was evaluated by immunocytochemistry.

RESULTS

In vitro, the phosphorylation of Smad2 was inhibited by botulinum toxin type A treatment. The expression levels of collagen types 1 and 3 were inhibited by botulinum toxin type A treatment, whereas those of matrix metalloproteinase-2 and matrix metalloproteinase-9 were enhanced. Gelatin zymography experiments confirmed enhanced matrix metalloproteinase-2 activity in collagen degradation. In vivo, botulinum toxin type A treatment reduced capsule thickness and Smad2 phosphorylation in silicone-induced capsules.

CONCLUSION

This study suggests that botulinum toxin type A plays an important role in the inhibition of capsule formation through the TGF-β/Smad signaling pathway.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

Ocular Adnexal Reconstruction for Cutaneous Periocular Malignancies

Although the majority of lesions present in the periocular region are benign, periocular cutaneous malignancies are certainly not uncommon and must be considered. The management of nonmelanoma cutaneous malignancies is predominately surgical with Mohs micrographic surgery or excision with frozen sections. The approach to reconstruction of the resulting defects depends on the defect location and size. When able, it is preferable to close lesions directly or with the recruitment of adjacent tissue in an effort to preserve the inherent anatomy. The eyelid's dynamic function is thus maintained, which is essential for optimal ocular surface protection. However, larger and more extensive defects will require complex reconstructions that are able to restore the necessary structural integrity to the eyelids. The authors review the various reconstruction approaches for defects of all sizes involving the periocular area including nonmarginal defects and defects of the lower and upper eyelids, as well as those of the medial canthal region.

Botulinum Toxin Off-Label Use in Dermatology: A Review

BACKGROUND

Botulinum toxin is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It is currently used for aesthetic treatments and in the focal hyperhidrosis. Recently, botulinum toxin has also been used experimentally in many other dermatological conditions with good results.

OBJECTIVE

To review and analyze the possible botulinum toxin off-label applications published.

METHODS

A retrospective review of the published data was conducted.

CONCLUSIONS

this potent drug can lead to several off-label indications of interest for dermatologists. Further clinical trials are still needed to better understand the real efficacy and safety of these applications and to standardize injection and dose protocols.

Novel Insights on Understanding of Keloid Scar: Article Review

Keloid scar, dermal benign fibro-proliferative growth that extends outside the original wound and invades adjacent dermal tissue due to extensive production of extracellular matrix, especially collagen, which caused by over expression of cytokines and growth factors. Although many attempts were made to understand the exact pathophysiology and the molecular abnormalities, the pathogenesis of keloid scar is yet to be determined. Even though there are several treatment options for keloid scars include combination of medical and surgical therapies like combination of surgical removal followed by cryotherapy or intralesional steroid therapy, the reoccurrence rate is still high despite the present treatment. In this review, PubMed, clinical key and Wright State Library web site have been used to investigate any update regarding Keloid disease. We used Keloid, scar formation, hypertrophic scar and collagen as key words. More than 40 articles have been reviewed. This paper reviews literature about keloid scar formation mechanism, the most recent therapeutic options including the ones under research.

Prevention of esophageal strictures after endoscopic submucosal dissection with the injection of botulinum toxin type A

BACKGROUND AND AIMS

The use of endoscopic submucosal dissection (ESD) for management of widespread superficial esophageal squamous carcinoma is closely associated with esophageal stenosis. We investigated the efficacy and feasibility of endoscopic injection of botulinum toxin type A (BTX-A) for preventing esophageal strictures after ESD for superficial esophageal squamous carcinoma.

METHODS

Sixty-seven patients with superficial esophageal squamous cell carcinomas with mucosal defects that exceeded one half of the circumference of the esophagus after ESD treatment were enrolled and randomly divided into 2 groups (group A, n = 33; group B, n = 34). Patients in group A (BTX-A group) were immediately injected with BTX-A after ESD, whereas patients in group B (control group) received ESD only. Endoscopy was performed when patients reported dysphagia symptoms and at 12 weeks post-ESD in patients without symptoms. Patients who experienced post-ESD esophageal strictures in both groups received bougie dilation.

RESULTS

The number of patients who experienced esophageal strictures in group A (per protocol analysis, 6.1%, 2/33; intention to treat analysis, 11.4%, 4/35) was significantly less than that seen in group B (per protocol analysis, 32.4%, 11/34; intention to treat analysis, 37.8%, 14/37) (P < .05). Moreover, the number of bougie dilation procedures was significantly lower in group A (mean, 1.5; range, 0-2) than in group B (mean, 2.8; range, 0-5) (P < .05).

CONCLUSIONS

Endoscopic injection of BTX-A was effective in preventing post-ESD esophageal strictures and decreasing the times of bougie dilation procedures. (

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-TRC-12003188.).

Botulinum Toxin Type A and the Prevention of Hypertrophic Scars on the Maxillofacial Area and Neck: A Meta-Analysis of Randomized Controlled Trials

Background

The purpose of the meta-analysis was to evaluate the efficiency of therapeutic botulinum toxin type A (BTX-A) in the prevention of maxillofacial and neck scars.

Methods and Findings

Information came from the following electronic databases: Medline, PubMed, Cochrane Library, and EMBASE (time was ended by August 31, 2015) to retrieve RCTs evaluating the effect of the BTX-A for hypertrophic scar on the maxillofacial or neck. All languages were included as long as they met the inclusion criteria. Here the effects of BTX-A were evaluated by comparing the width of the scar, patient satisfaction, and the visual analysis scores (VAS), respectively. Pooled weighted mean differences (WMDs), pooled odds ratios (ORs), and 95% confidence intervals (CI) were calculated. Nine RCTs covering a total of 539 patients were included. A statistically significant difference in scar width was identified between the BTX-A group and control group (non-BTX-A used) (WMD = -0.41, 95% CI = -0.68 to -0.14, P = 0.003). A statistically significant difference in patient satisfaction was observed between the BTX-A group and control group (OR = 25.76, 95% CI = 2.58 to 256.67, P = 0.006). And in patients regarding visual analysis scores (VAS), a statistically significant difference was also observed between the BTX-A group and control group (WMD = 1.30, 95% CI = 1.00 to 1.60, P < 0.00001).

Conclusions

This meta-analysis evaluates the efficacy of the BTX-A and confirms that BTX-A is a suitable potential therapy for the prevention of hypertrophic scars in patients in the maxillofacial and neck areas.

Botulinum toxin for the prevention and healing of wound scars: A systematic review of the literature

BACKGROUND

Botulinum toxin injections have been investigated for the treatment or prevention of hypertrophic scars in several clinical studies. However, its clinical effectiveness has not yet been established.

OBJECTIVE

To examine all available evidence that support the use of botulinum toxin injections for the treatment or prevention of hypertrophic scars in current clinical practice.

METHODS

A systematic review searching the MEDLINE (1966 to 2014), Scopus (2004 to 2014), Popline (1974 to 2014), ClinicalTrials.gov (2008 to 2014) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999 to 2014) databases together with reference lists from included studies was conducted.

RESULTS

Ten studies (255 patients) were included. Of these, 123 patients were injected with botulinum toxin type A, nine patients were offered botulinum toxin type B and the remaining 123 patients represented the control groups. Significantly improved cosmetic outcomes were observed among certain studies using the visual analogue scale (experimental group: median score 8.25 [range 6 to 10]) versus control group: median score 6.38 [range 2 to 9]; P<0.001) and the Stony Brook Scar Evaluation Scale (experimental group score: 6.7 versus control group score: 4.17; P<0.001) assessments. However, the methodological heterogeneity of the included studies, the lack of control group in the majority of them, the use of subjective scales of measurement and the frequent use of patient self-assessment precluded unbiased results.

CONCLUSIONS

Current evidence does not support the usage of botulinum toxin. Future randomized controlled trials are needed in the field to reach firm conclusions regarding its place in current clinical practice.

Botulinum toxin for the prevention and healing of wound scars: A systematic review of the literature

Background

Botulinum toxin injections have been investigated for the treatment or prevention of hypertrophic scars in several clinical studies. However, its clinical effectiveness has not yet been established.

Objective

To examine all available evidence that support the use of botulinum toxin injections for the treatment or prevention of hypertrophic scars in current clinical practice.

Methods

A systematic review searching the MEDLINE (1966 to 2014), Scopus (2004 to 2014), Popline (1974 to 2014), ClinicalTrials.gov (2008 to 2014) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999 to 2014) databases together with reference lists from included studies was conducted.

Results

Te n studies (255 patients) were included. Of these, 123 patients were injected with botulinum toxin type A, nine patients were offered botulinum toxin type B and the remaining 123 patients represented the control groups. Significantly improved cosmetic outcomes were observed among certain studies using the visual analogue scale (experimental group: median score 8.25 [range 6 to 10]) versus control group: median score 6.38 [range 2 to 9]; P<0.001) and the Stony Brook Scar Evaluation Scale (experimental group score: 6.7 versus control group score: 4.17; P<0.001) assessments. However, the methodological heterogeneity of the included studies, the lack of control group in the majority of them, the use of subjective scales of measurement and the frequent use of patient self-assessment precluded unbiased results.

Conclusions

Current evidence does not support the usage of botulinum toxin. Future randomized controlled trials are needed in the field to reach firm conclusions regarding its place in current clinical practice.

Botulinum toxin to improve results in cleft lip repair: a double-blinded, randomized, vehicle-controlled clinical trial

Background

Most patients with facial scarring would value even a slight improvement in scar quality. Botulinum toxin A is widely used to alleviate facial dynamic rhytides but is also believed to improve scar quality by reducing wound tension during healing. The main objective was to assess the effect of Botulinum toxin on scars resultant from standardized upper lip wounds.

Methods

In this double-blinded, randomized, vehicle-controlled, prospective clinical trial, 60 consecutive consenting adults undergoing cleft lip scar revision (CLSR) surgery between July 2010 and March 2012 were randomized to receive botulinum toxin A (n = 30) or vehicle (normal saline; n = 30) injections into the subjacent orbicularis oris muscle immediately after wound closure. Scars were independently assessed at 6-months follow-up in blinded fashion using: Vancouver Scar Scale (VSS), Visual Analogue Scale (VAS) and photographic plus ultrasound measurements of scar widths.

Results

58 patients completed the trial. All scar assessment modalities revealed statistically significantly better scars in the experimental than the vehicle-control group.

Conclusion

Quality of surgical upper lip scars, which are oriented perpendicular to the direction of pull of the underlying orbicularis oris muscle, is significantly improved by its temporary paralysis during wound healing.

Trial Registration

ClinicalTrials.gov NCT01429402

Updated scar management practical guidelines: non-invasive and invasive measures

Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities. An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes. The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

Up-to-date approach to manage keloids and hypertrophic scars: a useful guide

Keloids and hypertrophic scars occur anywhere from 30 to 90% of patients, and are characterized by pathologically excessive dermal fibrosis and aberrant wound healing. Both entities have different clinical and histochemical characteristics, and unfortunately still represent a great challenge for clinicians due to lack of efficacious treatments. Current advances in molecular biology and genetics reveal new preventive and therapeutical options which represent a hope to manage this highly prevalent, chronic and disabling problem, with long-term beneficial outcomes and improvement of quality of life. While we wait for these translational clinical products to be marketed, however, it is imperative to know the basics of the currently existing wide array of strategies to deal with excessive scars: from the classical corticotherapy, to the most recent botulinum toxin and lasers. The main aim of this review paper is to offer a useful up-to-date guideline to prevent and treat keloids and hypertrophic scars.

The effect of botulinum neurotoxin type A on capsule formation around silicone implants: the in vivo and in vitro study

This study confirms that botulinum neurotoxin type A (BoNT-A) decreases capsular contracture and elucidates a possible mechanism. Silicone blocks were implanted subcutaneously in 20 mice. The experimental groups received BoNT-A (1, 2·5 or 5 U) instilled into the subcutaneous pocket. After 30 days, periprosthetic capsules were harvested and evaluated. The effect of BoNT-A on the differentiation of human dermal fibroblasts to myofibroblasts in culture was examined by Western blot analysis. Changes in transforming growth factor-beta1 (TGF-β1) expression in cultured fibroblasts were determined by enzyme-linked immunosorbent assay (ELISA). In in vivo study, the thickness of capsules (P < 0·05) and the number of alpha-smooth muscle actin (α-SMA)(+) cells in capsules (P < 0·05) were significantly decreased in the experimental groups. TGF-β1 was significantly underexpressed in the experimental groups (P < 0·05). In in vitro study, BoNT-A did not significantly affect fibroblast viability. Western blot analysis showed that α-SMA protein levels were significantly decreased in the experimental groups (P < 0·05). Based on ELISA, the amount of TGF-β1 was significantly decreased in the experimental groups (P < 0·05), especially cells treated with a high dose of BoNT-A (P < 0·001). This study confirms that BoNT-A prevents capsular formation around silicone implants, possibly by blocking TGF-β1 signalling and interrupting the differentiation of fibroblasts to myofibroblasts.

Botulinum toxin type A: implications in wound healing, facial cutaneous scarring, and cleft lip repair

Botulinum toxin is a neurotoxin that has been utilized to induce chemo-denervation of muscles. Cutaneous wounds represent a special situation in which the tensile forces applied by these muscles on wound edges might have deleterious effects on the healing process. The aim of this review was to investigate such an effect and to review other mechanisms this toxin might have on the healing process. We also reviewed the role of botulinum toxin in the management of hypertrophic scars and cleft lip repair.

Use of botulinum toxin type A to improve treatment of facial wounds: a prospective randomised study

BACKGROUND

The tension vectors acting on the wound edges are transmitted to immature collagen fibres synthesised during the normal healing phase. This accounts for scar widening as well as hypertrophic and hyperpigmented scars. The aim of our study was to evaluate whether early injections of botulinum toxin type A (BTA), which induces temporary muscular paralysis, decreases tension vectors on wound edges and enhances scarring of facial wounds.

PATIENTS AND METHODS

Thirty patients with facial wounds were enrolled in this study and randomised into two groups with or without injection of BTA within 72 h postoperatively. BTA was injected into the facial muscles directly or indirectly involved in scar widening. Scars were assessed at a 1-year follow-up visit by patients using the Patient Scar Assessment Scale (PSAS) scale, by an independent evaluator using the Observer Scar Assessment Scale (OSAS) and the Vancouver Scar Scale (VSS), and by a board of six experienced medical specialists using the Visual Analogue Scale (VAS) with standardised photographs.

RESULTS

At the 1-year visit, 24 patients were reviewed and six patients were lost to follow-up. No statistically significant differences were found between the two groups for the PSAS, OSAS and VSS scores. However, the median VAS rated by the six evaluators was 8.25 for the botulinum toxin-treated group compared with 6.35 for the control group. This result was statistically different, demonstrating improved scarring with BTA.

CONCLUSIONS

Thanks to chemoimmobilisation, injections of BTA appear to improve cosmesis of facial wounds. Accordingly, they would be beneficial for use in young patients for wounds without tissue loss, lying perpendicular to the reduced tension lines of the skin of the face.

Botulinum toxin type A in the healing of chronic lesion following bilateral spasticity of gluteus muscle

Use of botulinum toxin is expanding as the clinical studies demonstrate new potential therapeutic applications. In rehabilitation, botulinum toxin is above all used as adjunct therapy for the treatment of spasticity, but it may prove useful for other atypical clinical situations. A 17-year-old man had a sub-arachnoid haemorrhage following the rupture of cerebral aneurism. The patient presented gluteus maximus and medius bilaterally spasticity that produced a chronic lesion in the intergluteal cleft, a flexed wrist and a flexed elbow. As treatment for this spasticity, a total of 100 U botulinum toxin type A were injected into the glutei muscles. This treatment allowed for application of topical medication and subsequently, chronic lesion healing. Botulinum toxin A may be an important therapeutic aid for clinicians faced with treating persistent pathological conditions caused by spasticity.

Kinetic and reaction pathway analysis in the application of botulinum toxin a for wound healing

A relatively new approach in the treatment of specific wounds in animal models and in patients with type A botulinum toxin is the focus of this paper. The indications or conditions include traumatic wounds (experimental and clinical), surgical (incision) wounds, and wounds such as fissures and ulcers that are signs/symptoms of disease or other processes. An objective was to conduct systematic literature searches and take note of the reactions involved in the healing process and identify corresponding pharmacokinetic data. From several case reports, we developed a qualitative model of how botulinum toxin disrupts the vicious cycle of muscle spasm, pain, inflammation, decreased blood flow, and ischemia. We transformed this model into a minimal kinetic scheme for healing chronic wounds. The model helped us to estimate the rate of decline of this toxin's therapeutic effect by calculating the rate of recurrence of clinical symptoms after a wound-healing treatment with this neurotoxin.

The use of botulinum toxin as primary or adjunctive treatment for post acne and traumatic scarring

BACKGROUND

Botulinum toxin has been utilised successfully in many facial and extra facial regions to limit superfluous movement. Scars, whether traumatic or disease-related, are treated with many modalities.

OBJECTIVE

To assess the available literature concerning the prophylactic use of botulinum toxin for the improvement in the cosmetic outcome of scars induced by surgery and to examine its role in the treatment of established scars alone, as also combined with other modalities.

MATERIAL AND METHODS

The results of the prophylactic use of botulinum toxin to limit the resultant scarring from surgery are examined by a literature review. The primary and adjunctive use of botulinum toxin in the treatment of post acne and post surgical and traumatic scars is explored by case examples.

RESULTS

Literature review and personal experience shows good Improvement in the appearance of scars with the use of botulinum toxin alone or with other adjuvant modalities in the treatment of scars.

CONCLUSION

Botulinum toxin would appear to be useful both in the prophylaxis and treatment of certain types of scars.

Nonhuman primate dermatology: a literature review

In general, veterinary dermatologists do not have extensive clinical experience of nonhuman primate (NHP) dermatoses. The bulk of the published literature does not provide an organized evidence-based approach to the NHP dermatologic case. The veterinary dermatologist is left to extract information from both human and veterinary dermatology, an approach that can be problematic as it forces the clinician to make diagnostic and therapeutic decisions based on two very disparate bodies of literature. A more cohesive approach to NHP dermatology - without relying on assumptions that NHP pathology most commonly behaves similarly to other veterinary and human disease - is required. This review of the dermatology of NHP species includes discussions of primary dermatoses, as well as diseases where dermatologic signs represent a significant secondary component, provides a first step towards encouraging the veterinary community to study and report the dermatologic diseases of nonhuman primates.

Treatment of hypertrophic scars with intralesional botulinum toxin type A injections: a preliminary report

BACKGROUND

Hypertrophic scar is the abnormal appearance of wound healing that usually causes major physical, psychological, and cosmetic problems. Treatment of the hypertrophic scar still is a dilemma due to the lack of effective and excellent methods and agents. Recent reports show that botulinum toxin type A (BTX-A) improves wound healing. Therefore, the authors hypothesized that BTX-A may be favorable for the improvement of hypertrophic scars.

METHODS

A total of 19 patients were randomly assigned to a prospective clinical study. At 1-month intervals, BTX-A (2.5 U per cubic centimeter of lesion) was injected in these patients for a total of 3 months. All the patients were followed up for at least half a year. Therapeutic satisfaction was recorded, and the lesions were assessed for erythema, itching sensation, and pliability.

RESULTS

The study was completed by 19 patients. At the half-year follow-up visits, all the patients showed acceptable improvement, and the rate of therapeutic satisfaction was very high. The erythema score, itching sensation score, and pliability score after the BTX-A injection all were significantly lower than before the BTX-A injection. The differences all were statistically significant (P < 0.01).

CONCLUSION

For the treatment of hypertrophic scars, doctors and patients both found BTX-A acceptable because of its better therapeutic results. Its effect of eliminating or decreasing hypertrophic scars was promising.

Effect of botulinum toxin type a on a rat surgical wound model

Objectives

The tension on a wound is one of the important factors that determine the degree of fibrosis and scar formation. We hypothesized that local botulinum toxin type A (Botox) induced paralysis of the musculature subjacent to a surgical wound with a skin defect would minimize the repetitive tensile forces on the surgical wound's edges, and this will result in a decreased fibroplastic response and fibrosis of the wound.

Methods

This is a prospective randomized experimental study. Two distinct surgical wounds were made to the dorsum of 15 adult rats, respectively. One of the 2 wounds was injected with Botox, and the other wound was used as a control, and this was done for all the rats' wounds. We evaluated the wound size, the degree of fibrosis and inflammation, the blood vessel proliferation, the thickness of the wound and the expression of transforming growth factor (TGF)-β1 in the wounds.

Results

There were significant differences of wound size at the 3rd and 4th week between the Botox and control groups (P<0.05). The Botox group showed less infiltration of inflammatory cells than the control group at the 2nd week (P<0.05). The Botox group showed a smaller number of fibroblasts and less fibrosis than the control group at the 4th week (P<0.05). The Botox group showed much strong collagen density than the control group at the 8th week (P<0.05). For the immunohistochemical staining, there was a lower transforming growth factor (TGF)-β1 expression in the Botox group than that of the control group at the 4th week (P<0.05).

Conclusion

The wounds of the Botox-treated group showed a larger wound size, less infiltration of inflammatory cells and less fibrosis, a much greater amount of collagen and a lower expression of TGF-β1 than did the control group. Botox might be used to decrease the fibrosis of a surgical wound without damaging the epithelial growth in situations for which decreased fibrosis is necessary, such as for treating laryngeal, tracheal and nasal stenosis.

Effect of botulinum toxin type a on a rat surgical wound model

OBJECTIVES

The tension on a wound is one of the important factors that determine the degree of fibrosis and scar formation. We hypothesized that local botulinum toxin type A (Botox) induced paralysis of the musculature subjacent to a surgical wound with a skin defect would minimize the repetitive tensile forces on the surgical wound's edges, and this will result in a decreased fibroplastic response and fibrosis of the wound.

METHODS

This is a prospective randomized experimental study. Two distinct surgical wounds were made to the dorsum of 15 adult rats, respectively. One of the 2 wounds was injected with Botox, and the other wound was used as a control, and this was done for all the rats' wounds. We evaluated the wound size, the degree of fibrosis and inflammation, the blood vessel proliferation, the thickness of the wound and the expression of transforming growth factor (TGF)-beta1 in the wounds.

RESULTS

There were significant differences of wound size at the 3rd and 4th week between the Botox and control groups (P<0.05). The Botox group showed less infiltration of inflammatory cells than the control group at the 2nd week (P<0.05). The Botox group showed a smaller number of fibroblasts and less fibrosis than the control group at the 4th week (P<0.05). The Botox group showed much strong collagen density than the control group at the 8th week (P<0.05). For the immunohistochemical staining, there was a lower transforming growth factor (TGF)-beta1 expression in the Botox group than that of the control group at the 4th week (P<0.05).

CONCLUSION

The wounds of the Botox-treated group showed a larger wound size, less infiltration of inflammatory cells and less fibrosis, a much greater amount of collagen and a lower expression of TGF-beta1 than did the control group. Botox might be used to decrease the fibrosis of a surgical wound without damaging the epithelial growth in situations for which decreased fibrosis is necessary, such as for treating laryngeal, tracheal and nasal stenosis.

Botulinum toxin A adjunctive use in manual chemabrasion: controlled long-term study for treatment of upper perioral vertical wrinkles

BACKGROUND

The treatment of perioral vertical wrinkles is a very common request from female patients as of their 40th decade of life. Actinic damage, cigarette smoking, loss of deep structures volume, sleep positions, orthodontic deformities, and dynamic components have been thought to cause this aesthetic problem.

OBJECTIVE

The objective was to investigate the combination of botulinum toxin type A (BoNTA) pretreatment of the orbicularis oris muscle with manual chemabrasion to increase its clinical efficacy in the therapy of upper perioral vertical rhytides.

METHODS

Twelve women presenting moderate to severe upper lip vertical rhytides were randomized to receive two unilateral BoNTA injections at the vermilion border, 1 week before chemabrasion (35% trichloroacetic acid followed by dermasanding) of the upper perioral cosmetic unit. Wrinkle severity was assessed by two blinded observers at baseline, 30 days, 90 days, 180 days, and 3 years by using a four-point Facial Wrinkle Severity Scale (FWSS).

RESULTS

From Day 90 to Year 3, the BoNTA-injected sides showed smaller grades in the FWSS than control sides (p<.05).

CONCLUSION

Previous injections of BoNTA improve short- and long-term results of chemabrasion in the upper lip region.

[Botulinum toxin treatment in the head and neck region: current aspects, developments, and problems]

Some interesting developments, aspects, and problems concerning botulinum toxin treatment of disorders of the head and neck region have recently been reported. These new approaches are discussed in this review. They include applications into mimic muscles (prevention of scar formation, treatment of depressions), into laryngeal muscles, and into the upper esophagus. In addition, treatment of different forms of headache and tinnitus as well as applications in the autonomic nervous system are addressed. Some of these options will shortly be put into clinical use, while others have to be checked further in clinical studies.

Hyperplastische Narben und Keloide

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar prevention and management continue to be important issues for the facial plastic surgeon. This article presents an overview on the pathogenesis of a scar and of the different types of scars. Differences between keloids, hypertrophic scars and normal scars include distinct scar appearance, histologic morphology and cellular function in response to growth factors. Recent advances in our understanding of the wound healing process reveal possible causes for hypertrophic scars and keloids. This information might assist in the development of efficacious prevention and treatment for hypertrophic scar and keloid formation. This article also describes the strategies available for scar prevention. Recommendations focus on the management of hypertrophic scars and keloids.

Novel cutaneous uses for botulinum toxin type A

Botulinum toxin type A is a neurotoxin produced by the bacterium Clostridium botulinum which causes a flaccid muscle paralysis. It has been used extensively in the field of dermatology for the treatment of dynamic rhytides and in the treatment of hyperhidrosis. Botulinum toxin has an excellent safety profile and few side effects when used for these purposes. Recently, botulinum toxin has also been used experimentally in a number of other dermatologic conditions with good results. These conditions include: persistent facial flushing, gustatory sweating and epiphora, anal fissures, familial benign pemphigus (Hailey-Hailey disease), dyshidrotic eczema, and following surgical wound closures. While randomized, controlled prospective trials are still needed to further understand the efficacy and safety of botulinum toxin in these conditions, anecdotal and case report data suggest that botulinum toxin is both safe and efficacious in these and many other procedures.

Botulinum toxin to improve facial wound healing: A prospective, blinded, placebo-controlled study

OBJECTIVE

To test whether botulinum toxin-induced immobillzation of facial lacerations enhances wound healing and results in less noticeable scars.

PATIENTS AND METHODS

In this blinded, prospective, randomized clinical trial, patients were randomized from February 1, 2002, until January 1, 2004, to botullnum toxin vs placebo injection into the musculature adjacent to the wound within 24 hours after wound closure. Blinded assessment of standardized photographs by experienced facial plastic surgeons using a 10-cm visual analog scale served as the main outcome measure.

RESULTS

Thirty-one patients presenting with traumatic forehead lacerations or undergoing elective excisions of forehead masses were included in the study. The overall median visual analog scale score for the botulinum toxin-treated group was 8.9 compared with 7.2 for the placebo group (P=.003), indicating enhanced healing and Improved cosmesis of the experimentally immobilized scars.

CONCLUSIONS

Botullnum toxin-induced Immobilization of forehead wounds enhances healing and is suggested for use in selected patients to improve the eventual appearance of the scar.