Page 165 - Read Online

Elhage et al. Plast Aesthet Res 2020;7:16 I http://dx.doi.org/10.20517/2347-9264.2020.03 Page 5 of 9

and PPP (P = 0.02) but there was no significant difference in median transverse or longitudinal hernia defect
size. Fascial closure was achieved in 95.7% of patients using a variety of techniques: 54 (77.1%) external
oblique release, 14 (20%) transversus abdominis release, and 2 (2.9%) retro-rectus repairs. Mesh was used in
[20]
all patients. At a mean follow-up of 34.5 month, 4 recurrences (5.7%) were reported . In 2019, the authors
updated their series with 10 more patients with overall data showing a similar reduction in VIH:VAC ratio
(16.3%), fascial closure (96.3%) and recurrence rates (6.2%) with a mean follow-up of 38.5 months.

[22]
In the only study comparing BTA injection techniques, Elstner et al. evaluated a total of 46 patients in a
prospective, observational fashion from 2015-2018. They compared two consecutive cohorts: 23 patients
received BTA at three sites bilaterally, targeting each muscle of the abdominal wall (EO, IO, TA) at each
injection site, and 23 patients who also received the same, but only targeting the EO and IO. Age, BMI,
transverse defect size, and number of failed hernia repairs were similar in both groups. Using serial CT
imaging, there was no difference in abdominal wall length gain between the groups (P = 0.37). All patients
underwent laparoscopic or laparoscopic-open-laparoscopic hernia repair with IPOM. Fascial closure
rate was 100%, and there were no recurrences at mean follow-up of 24 months. They concluded that BTA
injection of the TA can be omitted without compromising fascial closure in complex ventral hernias.

[23]
Nielsen et al. retrospectively evaluated the short-term safety of BTA for the treatment of large hernias
in 37 patients from two centers. The mean defect width was 12.1 cm, and 33 (89.2%) patients had no
prior hernia operations. All patients underwent open repair with 95% being retro-muscular. Component
separation was used in 15 (40.5%) patients and fascial closure was achieved in 100% of cases. Six patients
required readmission within 30 days however, three for wound complications. In total, nine patients
developed wound related complications. Outcomes beyond 30 days and recurrence rates were not reported.

[24]
In the most recent study by Chan et al. , 12 patients underwent preoperative BTA injections prior to
hernia repair. On CT imaging after BTA, there was a statistically significant increase in both left (P = 0.004)
and right (P = 0.014) sided mean abdominal wall lengths, with an increase in mean abdominal wall length
of 4.0 ± 2.2 cm per side. Nine patients underwent laparoscopic repair with IPOM, and one patient had a
robotic IPOM repair. The remaining two patients underwent laparoscopic-open-laparoscopic repair, one
with IPOM and the other with a retro-rectus mesh placement. Based on the description of the “Venetian
Blinds” surgical technique used, it appears that fascia was reapproximated in all patients although this was
not directly reported. No hernia recurrences at a median follow-up of 18.3 months was observed.

Complications and side effects of botulinum toxin A
Nine of ten studies in our review reported on specific BTA related complications or side effects [16-24] . Five
did not have any complications or side effects related to BTA administration [16,17,20,21,24] while the remaining
four reported side effects without major complications [18,19,22,23] .

[23]
Nielsen et al. reported one patient (2.7%) who had pain related to BTA injections. This was managed
without narcotic pain medications and resolved prior to surgery.

The remaining three studies shared a common theme of patients reporting a weak cough or sneeze
[18]
following BTA administration [18,19,22] . Farooque et al. found that in patients experiencing these symptoms,
this improved with application of an abdominal binder, and all resolved prior to surgery.

[19]
Rodriguez-Acevedo et al. found that several patients developed superficial bruising at the BTA injection
sites. In addition to the weak cough, patients also reported a sensation of bloating that resolved only after
the hernia repair. Four patients in their study also reported back pain after BTA injections but with unclear
duration. For these complaints, an abdominal binder again proved to manage symptoms adequately.