SAMCEP Society consensus on the treatment of upper facial lines with botulinum neurotoxin type A: A tailored approach

BACKGROUND

The safety and efficacy of botulinum neurotoxin type A (BoNTA) treatments are well established, but injection techniques, target muscles, and toxin doses continue to evolve, with each refinement producing improvements in treatment outcomes. The recommendations in this consensus move away from standard templates and illustrate how to tailor treatments to individual patterns and strengths of muscle activity, and patient preferences.

METHODS

Seventeen experts in the fields of plastic surgery, dermatology, ophthalmology, otorhinolaryngology, and neurology convened in 2022 to develop consensus-based recommendations for the use of botulinum toxin A for the treatment of horizontal forehead lines, glabellar frown lines, and crow's feet lines that reflect current clinical practice. The focus was on how to tailor injections to individual patients to optimize treatment outcomes.

RESULTS

For each upper face indication, consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is presented for commonly observed patterns of dynamic lines. Units of Inco are defined and the precise location of injection points, illustrated with the use of anatomical images.

CONCLUSION

This consensus provides up-to-date recommendations on the tailored treatment of upper facial lines based on the latest research and collective clinical experience of the expert injectors. Optimal outcomes require thorough patient evaluation, both at rest and during animation, using both visual and tactile cues; detailed understanding of facial muscular anatomy and how opposing muscles interact; and use of a BoNTA with high precision to target identified zones of excess muscle activity.

The emergence, spread and vanishing of a French SARS-CoV-2 variant exemplifies the fate of RNA virus epidemics and obeys the Mistigri rule

The nature and dynamics of mutations associated with the emergence, spread, and vanishing of SARS-CoV-2 variants causing successive waves are complex. We determined the kinetics of the most common French variant ("Marseille-4") for 10 months since its onset in July 2020. Here, we analyzed and classified into subvariants and lineages 7453 genomes obtained by next-generation sequencing. We identified two subvariants, Marseille-4A, which contains 22 different lineages of at least 50 genomes, and Marseille-4B. Their average lifetime was 4.1 ± 1.4 months, during which 4.1 ± 2.6 mutations accumulated. Growth rate was 0.079 ± 0.045, varying from 0.010 to 0.173. Most of the lineages exhibited a bell-shaped distribution. Several beneficial mutations at unpredicted sites initiated a new outbreak, while the accumulation of other mutations resulted in more viral heterogenicity, increased diversity and vanishing of the lineages. Marseille-4B emerged when the other Marseille-4 lineages vanished. Its ORF8 gene was knocked out by a stop codon, as reported in SARS-CoV-2 of mink and in the Alpha variant. This subvariant was associated with increased hospitalization and death rates, suggesting that ORF8 is a nonvirulence gene. We speculate that the observed heterogenicity of a lineage may predict the end of the outbreak.

[Does orbital exenteration still has a place in 2019?]

INTRODUCTION

Orbital exenteration is a radical anatomically and psychologically disfiguring procedure. It is mostly performed for management of orbital cancers or cancers with orbital involvement. The lack of benefit in terms of overall survival and the development of new molecular therapies (targeted therapies, immunotherapy) in recent years leads us to question its use. The goal of our review is to answer to the following question: is orbital exenteration a viable procedure in 2019?

MATERIALS AND METHODS

A literature review was performed using the PUBMED and MEDLINE databases. The following terms were used then crossed with each other: "orbital exenteration", "exenterated socket", "overall survival", "life expectancy", "orbital reconstruction", "socket reconstruction". Oncology articles from the past 15 years were included and separated into those in the oculoplastic literature and those in the ENT literature.

RESULTS

Nineteen articles were included in this review. Eyelid tumours represent the main etiology of orbital exenteration. Basal cell carcinoma is the most frequently incriminated tumor, while sebaceous carcinoma and conjunctival squamous cell carcinoma are the most frequently encountered in Asian series. Non-conservative orbital exenteration is the most prevalent surgery performed. Orbital reconstruction depends on the surgeon's speciality: healing by secondary intention and split thickness skin grafts are mostly performed by oculoplastic surgeons, whereas regional or free flaps are mostly performed by ENT surgeons. Cerebrospinal fluid leakage is the most common intraoperative complication, encountered in 0 to 13 % of cases. The most common postoperative complications are ethmoid fistula and infection of the operative site, encountered in 0 to 50 % and 0 to 43 % of cases respectively. Orbital exenteration allows surgical resection of R0 tumors in 42.5 % to 97 % of cases. Overall survival following orbital exenteration is 83 % (50.5-97) and 65 % (37-92) at 1 and 5 years respectively. Identified risk factors for poor overall survival are: age, tumor histology (worse prognosis with choroidal melanoma, better prognosis with basal cell carcinoma), non-R0 surgical resection, locally advanced tumors (size>20mm, BCVA<20/400 and the presence of metastases at diagnosis). Recent studies have demonstrated favorable outcomes when managing locally advanced basal cell carcinoma, lacrimal gland cancer and conjunctival melanoma with targeted therapies or immunotherapies without performing orbital exenteration.

CONCLUSION

Orbital exenteration remains a major part of our therapeutic arsenal. Although orbital exenteration has failed to demonstrate any overall survival benefit, it allows satisfactory local control of the disease with an increasingly less invasive procedure. The development of targeted therapies and immunotherapies may change our therapeutic decisions in the future.

[Oculoplastic complications of the excision of meningiomas with orbital extension]

INTRODUCTION

Meningiomas with orbital extension are the most frequent benign orbital tumors. The few studies available on the postoperative complications of their excision focus on the postoperative evolution of proptosis, visual acuity and visual field deficits. The goal of our study was to highlight the oculoplastic complications secondary to their excision.

MATERIAL AND METHOD

We identified all cases of meningiomas with orbital extension undergoing excision either neurosurgically or via an orbital approach in the ophthalmology and neurosurgery departments of Pasteur university medical center in Nice between February 2011 and January 2017. The data collection included the postoperative presence of proptosis, oculomotor disturbance, lid disorders, dry eye and trigeminal nerve damage.

RESULTS

Twenty-nine patients were included; 89.7 % were women. The mean age was 55 years. Postoperative complications included 25 % residual proptosis; 40.7 % oculomotor disturbance, 75 % of which regressed at least partially; 50 % ptosis, 21 % of which did not regress; 40 % dry eye; and in 21.4 % the trigeminal nerve was involved.

CONCLUSION

The management of meningiomas with orbital extension is difficult due to their anatomical location and requires joint neurosurgical and oculoplastic management. Sufficient follow-up is required before recommending surgery for oculomotor disturbances. The frequency of occurrence of ptosis with potential recommendation for surgery requires caution given the occurrence of trigeminal nerve involvement and dry eye syndrome.

[Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]

INTRODUCTION

Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific.

PURPOSE

To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations.

MATERIALS AND METHODS

This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology.

RESULTS

Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01).

DISCUSSION

Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated.

CONCLUSION

The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.

[Blepharoplasty and upper eyelid malposition]

Upper eyelid blepharoplasties are sometimes performed for functional purposes, but more often for cosmetic reasons. Upper eyelid malpositions, such as ptosis or lid retraction, are frequent and of varying causes. It is not rare for patients to present upper lid malposition, with or without functional consequences, associated with myocutaneous excess. Both functional and cosmetic outcomes are important. This article explores the etiologies of these pathologies and current surgical procedures. Furthermore we will discuss the advantages of combined procedures and different approaches to treat these concomitant pathologies.

[Difficult blepharoplasties]

The effectiveness expected from aesthetic blepharoplasty is strongly related to the attention paid during the preoperative examination. The protocol as well as the proportioning of the surgical gesture are indeed likely to be influenced by the clinical assessment.

OBJECTIVES

To emphasize the significant points of the local and general examination that have to be raised in order to reduce the incidence of complications. The delicate situations are detailed and illustrated. The contribution of the complementary investigations and the various surgical strategies are evoked. In the second part are summarized the early and late complications of aesthetic blepharoplasties as well as their management if they could not be avoided.

[Primary signet ring cell carcinoma of the eccrine sweat gland in the eyelid. Immunohistochemical and ultrastructural study of a case]

We report a case of a 45-year-old woman who exhibited a primitive eccrine sweat gland carcinoma of the eyelid. Histological study showed cellular proliferation with an Indian file pattern and some signet ring cells with sialomucin secretion. Immunohistochemical study demonstrated these cells to be positive with the anticytokeratin, anti-EMA, anti-HMFG, antiestrogen receptor and antiprogesterone receptor antibodies. Ultrastructural study showed intracytoplasmic vacuoles with numerous microvilli at the apical side. Differential diagnosis with a metastasis from a mammary adenocarcinoma is difficult and a complete staging is necessary to confirm the primitive origin of the tumor. The behavior of this tumor is marked by locoregional recurrence.

[Necrotizing fasciitis of the eyelids and orbit: a life-threatening ophthalmological emergency]

INTRODUCTION

Necrotizing fasciitis is an extremely serious exceptional infectious process affecting subcutaneous soft tissues with skin gangrene and vascular thromboses. Starting from a case repat of necrotizing fasciitis of the eyelids and orbit, which occurred in a child of 4, we analyse the early diagnostic elements and the urgency of treatment of a pathology which can rapidly be life-threatening.

OBSERVATION

A child, aged 4 presented a necrotizing fasciitis of the eyelid and orbit with serious toxic shock, after minor skin abrasion.

RESULT

Resuscitation and parenteral antibiotic therapy were not sufficient to stop the necrotizing process, which required surgical debridement of gangrenous tissues.

DISCUSSION

Necrotizing fasciitis is a rare affection with fatal local and general prognosis. Location on the orbit and eyelids is extremely rare, with only a score of cases recorded in the literature, principally in adults. Our observation shows the possibility of occurrence in a young child and found the typical features of the pathology: minor initial trauma, beta hemolytic streptococcus, extremely fast progression requiring resuscitation, extensive antibiotic therapy and surgical excision of the gangrenous tissues. Eyesight remained intact, but cases of blindness have been described in the literature. Secondary reconstructive surgery on the eyelids may be necessary.

CONCLUSION

Urgent diagnosis of this exceptional pathology that may affect the young child and prompt antibiotic therapy and surgical debridement are the only guarantees of survival of infected patients.

[HIV-positive newborns via maternal-fetal transmission. Early ophthalmic lesions]

Since January 1986, the authors have examined twenty infant HIV positives. In two cases specially, some serious and precocious ophthalmic lesions have been found : an ophthalmic zona appeared at the age of three months, a cytomegalovirus retinitis diagnosed at the age of six months. From this series, the particularities of the HIV infection by maternal-fetal transmission are discussed.