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Botulinum Toxin-A as an Adjunct in Digital Replantation
Nicholas Bastidas, MD1; Orianna Cohen1; Zhi Yang Ng1; Oren Z. Lerman, MD2; Daniel Ceradini1; Pierre Saadeh1
1Institute of Reconstructive Plastic Surgery, New York University School of Medicine, New York, NY; 2Plastic Surgery, Lennox Hill Hospital, New York, NY

Introduction: Vasospasm of the digital arteries after replantation surgery is particularly problematic as it often leads to vessel thrombosis and subsequent loss of arterial inflow. Botuilinum Toxin-A (Botox) has been demonstrated in the literature to be an effective treatment for vasospastic disorders of the hand, including Raynaudís phenomenon.  We hypothesize that using a single dose of Botox intra-operatively may allow for a temporary, yet adequate, sympatholytic effect, and prevent the occurrence of vascular smooth muscle mediated vasospasm which often leads to replant failure (via vessel thrombosis).

Methods: An in vivo rodent vasospasm model was used to evaluate the timing of effect of a perivascular injection of Botox-A (20 units) into the pedicle of SIE flaps.  Perfusion of the flaps was quantitatively assessed using color laser Doppler flow instrumentation (Moor Instruments).  Vasospasm was induced using mechanical stimulation, intra-muscular epinephrine and topical epinephrine and flow was determined at 1hr, 24hrs, 48hrs, 72hrs, and one week post-injection. 

An IRB/FDA approved randomized single blind clinical trial was initiated at Bellevue Hospital and informed consent obtained from participants in the trial. 

Experimental: Rodent SIE flaps pre-treated with Botox maintained almost normal perfusion (82-100% of total flow) in response to vasospastic challenges when compared to controls (22-45% of total flow) with a significant effect on post-treatment day three.  This effect was maintained up to at least one-week post-operative.

Clinical: One of seven revascularizations (14.3%) was taken back for exploration in the botox group (2hours post-injection).  Upon exploration, the inflow returned without necessitating a revision of the anastomosis, confirming our suspicion for vasospasm.  Two of eight (25%) revascularizations was taken back in the control group and found to have arterial thrombosis (POD #1 and POD #3), one of which was salvaged with a vein graft.

Conclusions: Botox-A significantly reduces vasospasm in response to challenges (mechanical stimulation and topical epinephrine) while maintaining flap perfusion in the rodent model, with a significant effect on post-operative day three.  Preliminary results of the clinical trial suggest Botox to be a useful adjunct in reducing incidences of vasospasm and loss of the replanted part.  More patients must be enrolled in the clinical trial to obtain statistical significance.

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