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Noninvasive aesthetic procedures are continuously on the rise1 and every year there is an increase in uptake of botulinum toxin as one of the most popular procedures performed in the United States and perhaps the world. In addition to the well-known anticholinergic effect (responsible for muscle-relaxation action), there is also increasing evidence of the antinociceptive effect, likely due to inhibition of neurogenic inflammation,2 which is medicated by calcitonin gene-related peptide (CGRP), substance P, and blockade of local glutamate release that leads to local edema.3 It is difficult to quantify the utilization of botulinum toxin for its therapeutic uses as currently there is no tracking method of this modality and one may be surprised that the therapeutic utilization maybe as high as the aesthetic market growth.

The authors of this paper4 have focused their animal study on a very specific problem, which includes whether myotomy alone can be beneficial in postoperative muscle weakness, as it relates to some of the facial procedures that are commonly performed. The study evaluated three animal groups: group A underwent myotomy of the Latissimus Dorsi muscle; group B underwent myotomy and injection of botulinum toxin A (BtxA) into the severed muscle; group C injection of BtxA alone. Clinically, rendering a particular muscle inactive with a myotomy and/or removal of a portion of the muscle has not always been successful. Even with placing interposition allo- or autografts, the results have been mixed and unpredictable.5 One wonders why some of the results are so unpredictable and can this be more related to a particular surgical technique or does the muscle have the capability of regaining function? The authors of this study have histologically evaluated the muscle in all three groups and the only histological significance found between the three treated groups, was the increased fat infiltration of the myotomy + BtxA group. Even though this is the only histological significance in this healing muscle group, it can possibly have major clinical implications. Many clinical studies have shown the correlation of the fat infiltration into the skeletal muscle as a poor correlation of muscle function and progression and further loss of function.6,7 In a recent clinical study, the radiographic signs of muscle degeneration in patients with low back pain was evaluated and three principal signs of muscle degeneration were detected on imaging: decreased muscle size, decreased radiographic density, and increased fat deposits.8

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