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Unique use of botulinum toxin to decrease adductor tone and allow surgical excision of vulvar carcinoma

Here, we present the case of an 86-year-old woman with vulvar carcinoma requiring surgical resection and with Parkinson's disease with severe spasticity and contractures of the lower extremities. Because of the patient's severe contractures and spasticity (her knees could only be separated by 2 cm with sustained abducting force), surgical positioning and access to the vulva were impossible. The patient was admitted, intending to undergo surgery after injection with botulinum toxin (BTX) to hip adductors and intensive physical therapy. After confirmed healed hip arthroplasty, the patient underwent BTX injection (400 U) to her bilateral adductor brevis, adductor longus, adductor magnus, and semimembranosus and semitendinosus muscles on day 2 of her hospital stay. On day 3, a physical therapist began a twice-a-day stretching program. An adjustable abduction brace was custom-made to provide sustained stretching. On day 9, the patient underwent wide local excision of vulvar carcinoma with the abductor brace in place. The patient tolerated the surgery well and was discharged home on day 11 with continuous physical therapy. Upon discharge, the distance between the patient's knees was 14 cm. This unique case demonstrated a new indication for BTX treatment in the preoperative setting to allow surgical positioning and access.