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Botox to the Rescue

Upton, Joe M.D.; Garcia, Jesus M.D., Ph.D.; Liao, Eric M.D., Ph.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 38e
doi: 10.1097/PRS.0b013e318194d22f
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The serendipitous applications of botulinum toxin in clinical medicine have been interesting. We recently salvaged a pediatric double-toe transfer with this drug.

Our patient was a 4-year-old child who as a 2-lb neonate sustained subtotal loss of the thumb and index and long fingers secondary to ischemia precipitated by an unrecognized tight dressing. The zone of injury and swelling involved the entire hand. When the patient was 2½ years old, one second toe was transferred to the thumb position without difficulty and the radial artery in the distal forearm was used as the donor artery. One year later, a double second toe–to–third toe transfer from the other foot was used to reconstruct the phalangeal segments of the index and long digits. The surgery progressed well and the common digital artery (internal diameter, 0.8 mm) to the second web space was used as the donor artery. Heparin therapy was started. During the first two postoperative days the pulse oximeter signals decreased every time the child became restless, was spongebathed, or went for a stroll with her parents in the air-conditioned corridor. On the third day (Sunday evening) the digits became white and she was taken back to the operating room for another exploration and revascularization. An intercalated vein graft was used after segmental resection of the donor artery (Fig. 1). Pulse oximeter readings returned to 99 percent.

Fig. 1.
Fig. 1.:
(Left) The appearance of the white digits on postoperative day 4. (Center) The intact anastomoses and no evidence of thrombosis within the first vein graft. (Right) The second vein graft in situ.

Two days later, the same sequence of events occurred. The drama and anxiety had intensified within the family, which had been through the initial iatrogenic injury. The graft was explored and replaced with a vein graft of equal diameter. No thrombus was present within the graft, and the previous anastomoses were clean. We were still working within the original zone of trauma, but debrided the donor artery to the level of the proximal palmar arch. It was time to get creative. Aware of Allen Van Beek's use of botulinum toxin type A for vasospasm in patients with collagen disorders, we injected 10 U of botulinum toxin into the proximal palm, the radial and ulnar artery locations of the distal forearm. The digits have remained pink since, and pulse oximeter reading have all been above 98 percent. There have been no systemic side effects. Syndactyly release between the two digits will be performed in 6 months.

We were aware of Allen Van Beek's observation, recently reported,1 that vasospasm could be prevented by the use of botulinum toxin type A and did not hesitate to use it here while working well within the original zone of previous trauma, which was much more susceptible to vasospasm. The stakes could not have been higher in our patient, who had sustained an iatrogenic injury, which was reconstructed with an elective double-toe transfer. We do not speculate as to the precise mechanism of action of the autonomic or smooth muscle blockade, but are most appreciative of Dr. Van Beek's simple observation several years ago. The take-home message for residents is: read the journals!

Joe Upton, M.D.

Jesus Garcia, M.D., Ph.D.

Eric Liao, M.D., Ph.D.

Chestnut Hill, Mass.


1. Van Beek AL, Lim PK, Gear AJ, Pritzker AR. Management of vasospastic disorders with botulinum toxin A. Plast Reconstr Surg. 2007;119:217–226.

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