The Effect of Depressor Anguli Oris Muscle Block on Facial Symmetry in Synkinetic Facial Paralysis Patients and Its Role in Preoperative Assessment.

BACKGROUND: Depressor anguli oris muscle hypertonicity in synkinetic facial paralysis patients may have an overpowering antagonistic effect on facial symmetry. Depressor anguli oris muscle block is a crucial diagnostic test before any treatment planning. Presented is the largest patient cohort analysis to date on static and dynamic facial symmetry changes after depressor anguli oris muscle block. METHODS: Unilateral synkinetic patients with depressor anguli oris muscle hypertonicity were included. Resting symmetry and smile modiolus angle, excursion, and exposure of teeth were measured on both synkinetic and healthy hemifaces before and after depressor anguli oris muscle block using Emotrics and FaceGram photographic analyses. RESULTS: Thirty-six patients were included. Before depressor anguli oris block, resting modiolus height was elevated on the synkinetic side (p = 0.047). During open-mouth smile, reduced modiolus angle (p < 0.0001), modiolus excursion (p < 0.0001), and exposure of teeth (p < 0.0001) were observed on the synkinetic hemiface. After depressor anguli oris block, resting modiolus height became symmetric (p = 0.64). During open-mouth smile, modiolus angle and exposure of teeth significantly increased (both p < 0.0001); excursion did not improve on the synkinetic side (p = 0.13) but unexpectedly improved in open-mouth smile on the healthy side (p = 0.0068). CONCLUSIONS: Depressor anguli oris muscle block improved resting symmetry and modiolus angle and exposure of teeth during smile, demonstrating the inhibitory mimetic role of a hypertonic depressor anguli oris muscle in synkinesis. It is a critical diagnostic and communication tool in the assessment and treatment planning of depressor anguli oris muscle hypertonicity, suggesting the potential effects of future depressor anguli oris myectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Effect of Botulinum Toxin Injection on Asymmetric Lower Face with Chin Deviation.

The purpose of this study was to compare the efficacy of botulinum toxin (BoNT) in masseter muscle reduction depending on the amount of chin deviation. Exploring distinctive effects of BoNT relative to the characteristics of facial asymmetry will aid in planning and predicting treatment outcomes. Sixteen adult volunteers were classified into two groups according to the degree of menton deviation observed in posteroanterior cephalograms. Eight had a menton deviation of 3 mm or more and the other eight had less than 3 mm. A total of 25 Units of BoNT was injected into the unilateral masseter muscle of the prominent side for each participant. Changes in the volume and bulkiest height of the lower face on each side were measured with a 3D laser scan at four time points: before and 4, 8, and 12 weeks after the injection. Two-way mixed ANOVA was employed for analyses. The volume and bulkiest height of the injected side decreased over time in both types of asymmetry, with significant differences at each time point. The reductions in the volume and bulkiest height were significantly greater in subjects without chin deviation. The reductions in the volume and bulkiest height of the lower face using BoNT are more effective for subjects without chin deviation.

Fibrous dysplasia of the orbital region: Series of 12 cases and review of the literature.

PURPOSE: Fibrous dysplasia (FD) is a benign fibro-osseous developmental disorder of growing bone, sometimes involving the craniofacial skeleton (CFD). We wish to present a patient series with CFD of the orbital region and discuss treatment modalities. METHODS: Twelve patients were referred for orbital CFD in the Nantes University Hospital between 2000 and 2018 and studied according to the clinical parameters, radiological features, and modalities of treatment. RESULTS: The mean age was 25.6 years. Ten patients exhibited facial asymmetry with vertical globe dystopia (75%), proptosis (58%) and facial bump (50%). The disease was monostotic in 83% of patients, involving the frontal bone (25%), the sphenoidal bone (33%), the fronto-sphenoidal complex (25%), and the skull base (17%). Unilateral radiological proptosis was found in 7 patients, with a mean protrusion 3.9mm. The optic canal was involved in 75% of patients, with no functional impairment. Three patients were treated with bisphosphonate therapy to stop progression of the disease; 6 patients were given a bone remodelling procedure with good aesthetic outcomes. CONCLUSION: The orbit is a rare localization for FD causing aesthetic and functional disabilities. Medical and surgical treatment can be proposed as part of a multidisciplinary approach.

Facial nerve palsy presenting as rare neurological complication of Kawasaki disease: A case report.

RATIONALE: Facial nerve palsy (FNP) is one of the rare neurologic symptoms of Kawasaki disease (KD), associated with a higher incidence of coronary arteries lesions and may be an indicator of more severe disease. PATIENT CONCERNS: A 3-month-old male infant with persistent fever, irritability, and facial asymmetry. DIAGNOSES: KD with FNP. INTERVENTIONS: The infant received intravenous immunoglobulin (IVIG) (2 g/kg/16 hours) and aspirin (50 mg/kg/day) were started on the 8th day of illness. OUTCOMES: Fever and FNP resolved within 48 hours after IVIG treatment. The inflammatory markers all improved to normal or near-normal levels before discharge; all infectious studies returned negative. His left facial weakness was unappreciable at day of discharge. LESSONS: FNP associated with KD is an uncommon finding but may indicate an increased risk of coronary artery involvement. KD should always be kept in mind in the differential diagnosis of a child who presents with prolonged unexplained fever, even with incomplete diagnostic features, as well as the need to be aware of unusual manifestations, such as FNP.

Botulinum toxin therapy of hemifacial spasm: bilateral injections can reduce facial asymmetry.

Botulinum toxin (BT) is the treatment of choice for hemifacial spasm (HFS). When BT is injected into the affected side, patients may experience increased facial asymmetry. We wanted to evaluate in a prospective, randomised, placebo-controlled study whether bilateral BT injections may reduce this facial asymmetry. For this, we treated 19 HFS patients with unilateral and 24 with bilateral BT therapy using CBTX-A (Lanzhou Biological Products Institute, Lanzhou, China). BT doses on the affected side were standard doses, on the non-affected side they were one-third of those. Facial asymmetry was studied with the Sunnybrook facial grading system (SFGS), the Facial Clinimetric Evaluation Scale (FaCE), the Symmetry Scale for Hemifacial Spasm (SSHS) and a self-assessment scale. As shown in SFGS and SSHS, bilateral BT therapy reduces facial asymmetry, whilst unilateral BT therapy increases it. Both effects are more pronounced during voluntary facial movements than at rest. BT effect delay, BT effect duration, adverse effect frequency and severity were not affected. FaCE total score, some of its subscores and the self-assessment scale did not show an effect. Bilateral BT therapy may improve the outcome of BT therapy for HFS without producing additional adverse effects. This strategy, however, raises drug costs (by about a third). Using even higher doses in the non-affected side may intensify the improvement even further. Future studies may also monitor the patient's quality of life and the naïve public's overall perception of the patient's facial expression.

Toxina botulínica para tratamento de síndrome do Choro Assimétrico: relato de caso / Botulinum toxin in the treatment of asymmetric crying face syndrome: a case report

Síndrome do choro assimétrico é uma condição congênita secundária à hipoplasia ou ausência do músculo depressor do ângulo da boca. Trata-se de uma condição não tão incomum que pode cursar com assimetria facial ao chorar e sorrir, além de poder estar associadas a outras malformações congênitas. Crianças com essa deformidade podem sofrer dificuldades psicossociais e introversão. O arsenal terapêutico dessa condição já foi estudado e discutido na literatura com ênfase em abordagens cirúrgicas e invasivas. Relatamos aqui um caso de uma criança de 9 anos com essa síndrome, tratada, de forma menos invasiva, com toxina botulínica, com um bom resultado e satisfação.

Asymmetric crying face syndrome is a congenital condition secondary to hypoplasia or absence of the depressor muscle at the mouth angle. It is a common condition that presents with facial asymmetry while crying and smiling and may be associated with other congenital malformations. Children with this deformity may experience psychosocial difficulties and introversion. The therapeutic arsenal of this condition has already been studied and discussed in the literature with an emphasis on surgical and invasive approaches. We report here a case of a 9-year-old child with this syndrome, treated less invasively with botulinum toxin, with good result and satisfaction.

Botulinum toxin treatment for facial palsy: A systematic review.

BACKGROUND: Facial palsy may be complicated by ipsilateral synkinesis or contralateral hyperkinesis. Botulinum toxin is increasingly used in the management of facial palsy; however, the optimum dose, treatment interval, adjunct therapy and performance as compared with alternative treatments have not been well established. This study aimed to systematically review the evidence for the use of botulinum toxin in facial palsy. METHOD: The Cochrane central register of controlled trials (CENTRAL), MEDLINE(R) (1946 to September 2015) and Embase Classic + Embase (1947 to September 2015) were searched for randomised studies using botulinum toxin in facial palsy. RESULTS: Forty-seven studies were identified, and three included. Their physical and patient-reported outcomes are described, and observations and cautions are discussed. DISCUSSION: Facial asymmetry has a strong correlation to subjective domains such as impairment in social interaction and perception of self-image and appearance. Botulinum toxin injections represent a minimally invasive technique that is helpful in restoring facial symmetry at rest and during movement in chronic, and potentially acute, facial palsy. Botulinum toxin in combination with physical therapy may be particularly helpful. Currently, there is a paucity of data; areas for further research are suggested. A strong body of evidence may allow botulinum toxin treatment to be nationally standardised and recommended in the management of facial palsy.

Application of Local Injection of Botulinum Toxin A in Cosmetic Patients with Congenital Drooping Mouth Corner.

OBJECTIVE: This study aimed to investigate the clinical application and efficacy of local injection of botulinum toxin A (BTX-A) at the depressor anguli oris in patients with congenital drooping mouth corner. METHODS: From September 2013 to March 2015, 36 cosmetic patients received local injections of botulinum toxin A at the depressor anguli oris, with 1-3 injection sites in the moving region of the depressor anguli oris on each side. At each injection site, 2-4 U of BTX-A was injected, and the total dose for any unilateral treatment did not exceed 8 U. The change in the degree of drooping of the mouth corner before and after the injection was analyzed using statistical methods. The clinical efficacy, preservation time, and adverse reactions were observed. RESULTS: The degree of drooping of the mouth corners of the cosmetic patients before the treatment was compared with that at 1 month after using a paired t test, and the difference was statistically significant, with P < 0.01. The treatment results were satisfactory, and the effect was preserved for 6-9 months. None of the 36 cosmetic patients had any complications of bruising, infection, dysfunction in opening and closing the mouth, smile asymmetry, drooling, or dysarthria after the injection. CONCLUSIONS: The local injection of BTX-A at the depressor anguli oris can effectively lift a drooping mouth corner, thereby improving the depressed, stern, and aged appearance of the face. The performance of this treatment is simple, safe, and easy to perform in clinical applications. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Epidemiologic Overview of Synkinesis in 353 Patients with Longstanding Facial Paralysis under Treatment with Botulinum Toxin for 11 Years.

BACKGROUND: Patients with longstanding facial paralysis often exhibit synkinesis. Few reports describe the prevalence and factors related to the development of synkinesis after facial paralysis. Botulinum toxin type A injection is an important adjunct treatment for facial paralysis-induced asymmetry and synkinesis. The authors assessed the clinical and epidemiologic characteristics of patients with sequelae of facial paralysis treated with botulinum toxin type A injections to evaluate the prevalence of synkinesis and related factors. METHODS: A total of 353 patients (age, 4 to 84 years; 245 female patients) with longstanding facial paralysis underwent 2312 botulinum toxin type A injections during an 11-year follow-up. Doses used over the years, previous treatments (electrical stimulation, operations), and how they correlated to postparalysis and postreanimation synkinesis were analyzed. RESULTS: There was a significant association between cause and surgery. Most patients with facial paralysis caused by a congenital defect, trauma, or a tumor underwent reanimation. There were no sex- or synkinesis-related differences in the doses used, but the doses were higher in the reanimation group than in the no-surgery group. Synkinesis was found in 196 patients; 148 (41.9 percent) presented with postparalysis synkinesis (oro-ocular, oculo-oral) and 58 (16.4 percent) presented with postreanimation synkinesis. Ten patients presented with both types. CONCLUSIONS: This study determined the high prevalence (55.5 percent) of synkinesis in patients with longstanding facial paralysis. Postparalysis synkinesis was positively associated with infectious and idiopathic causes, electrical stimulation, facial nerve decompression, and no requirement for surgery. Postreanimation synkinesis was present in 28.2 percent of reanimated patients and was significantly associated with microsurgical flaps, transfacial nerve grafting, masseteric-facial anastomosis, and temporalis muscle transfers.

Aesthetic use of BoNT: Options and outcomes.

There are a multitude of uses for BoNT in the aesthetic realm. Efficacy has been shown in softening glabellar creases, crows feet, forehead rhytides, and in correcting facial asymmetries, including mild eyelid ptosis. Facial shape can be altered through injections of BoNT into masseter, and smiles can be altered with BoNT. Clinical examples of the above will be shown, as well as adverse outcomes with inaccurate injection techniques.

Contralateral botulinum injections in patients with residual facial asymmetry and contralateral hyperkinesis after primary facial palsy surgery.

AIM: In patient with facial paralysis, facial appearance and muscular ability are impaired, and the psychological integrity is affected. Botulinum toxin A may be used to improve facial symmetry in patients suffering with facial palsy reducing the progressive contralateral hyperkinesis and facial asymmetry after primary surgery for facial paralysis. MATERIAL OF STUDY: Six patients, whom have been suffering unilateral facial palsy with an House-Brackmann score grade from III to VI, were included in this study for a residual facial asymmetry and contralateral hyperkinesis after previous facial reanimation. They were treated with 50 units of botulinum toxin type A injected in muscles of the unaffected side of face to improve muscular ability and facial symmetry. RESULTS: This study demonstrated reduction in contralateral hyperkinesis and facial asymmetry that lasted approximately 120 days. All patients reported satisfactory results with the treatment. COMMENTS: Botulinum toxin type A injections improved facial asymmetry and muscular function in all patients. DISCUSSION AND COMMENTS: Botulinum toxin type A injections may be an indispensable technique as a nonsurgical treatment or as a complementary measure in postsurgical treatments and should be certainly considered for temporary or permanent asymmetries in patients who suffer from facial palsy. CONCLUSIONS: Contralateral botulinum toxin type A injection was useful in reducing muscular hyperkinesis in patients with residual facial asymmetry after primary surgery for facial palsy, improving aesthetic and functional facial recovery with not widely common adverse events.

Effect of a second injection of botulinum toxin on lower facial contouring, as evaluated using 3-dimensional laser scanning.

BACKGROUND: Botulinum toxin type A (BoNT-A) is widely used to improve the lower facial contour. OBJECTIVE: To determine the difference in the changes in the lower facial contour achieved with 1 and 2 sessions of BoNT-A injections using 3-dimensional (3D) laser scanning. MATERIALS AND METHODS: Twenty volunteers were randomly divided into 2 groups. Group I (n = 10) received a single injection, whereas Group II (n = 10) received 2 sessions of injections, the second being administered 4 months after the first. Each injection comprised of 25 U of BoNT-A and was administered to the masseter muscle bilaterally. Evaluation of the effect of BoNT-A injection was performed using 3D laser scan images obtained before the injection and 6 months thereafter in Group I, and before the first injection and 6 months thereafter in the Group II. RESULTS: The mean changes in the volume and thickness in Group I were -1,186 mm and -1.52 mm, respectively; the corresponding changes were -4,072 mm and -3.84 mm in Group II. The reductions were significantly greater in Group II than in Group I. CONCLUSION: The administration of a second BoNT-A injection is effective for better aesthetic results for the lower facial contour.

Comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA at the 1: 3 conversion ratio for the treatment of asymmetry after long-term facial paralysis.

BACKGROUND: Botulinum toxin A injection into the nonparalyzed side is used to treat asymmetry resulting from facial palsy. OnabotulinumtoxinA and abobotulinumtoxinA units are not equivalent. The authors compared the conversion ratio of 1:3 in patients with facial palsy. METHODS: Fifty-five patients (age, 16 to 67 years; 43 women) with longstanding facial palsy were randomly treated with either onabotulinumtoxinA (n = 25) or abobotulinumtoxinA (n = 30) injections into the nonparalyzed side. Adverse effects, facial symmetry, subjective satisfaction, and Facial Disability Index were assessed after 1 and 6 months. RESULTS: The incidence of adverse effects was higher with abobotulinumtoxinA (93.3 percent versus 64.0 percent; p = 0.007). Clinical scores of the nonparalyzed side decreased after 1 month and increased again at 6 months, with no between-group differences. Scores of the paralyzed side were lower in the onabotulinumtoxinA group before treatment, but similar in both groups thereafter. The paralyzed side scores increased after 1 month, and at 6 months were still higher than the pretreatment scores in both groups. Subjective assessment improved at all time points compared with pretreatment scores and differed between the two groups only at 1 month, when the abobotulinumtoxinA group was a bit too paralyzed. The physical function and social/well-being function subscales of the Facial Disability Index did not differ between the two groups. CONCLUSIONS: Both toxins efficiently reduced asymmetry in patients with facial palsy. Adverse effects were higher with abobotulinumtoxinA at an equivalence ratio of 1:3. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Injecting botulinum toxin at different depths is not effective for the correction of eyebrow asymmetry.

BACKGROUND: It is theorized that brow elevation after treatment with botulinum toxin Type A (BoNT-A) results from inactivation of the brow depressors. Expert consensus is that increased injection depth delivers more BoNT-A to these depressors and causes increased elevation. This technique is applied to the correction of brow height asymmetry. OBJECTIVE: To compare changes in brow height after deep versus shallow BoNT-A in patients with brow asymmetry. METHODS: A prospective split-face analysis was performed on 23 women with eyebrow-height asymmetry. Subjects received 64 units of BoNT-A, divided among 16 injection sites in the glabella, forehead, and lateral canthal area. On the side where increased brow lift was desired, deep injections were performed and shallow injections on the opposite side. Photographs were taken at baseline and Week 4 for comparison measurements. RESULTS: All 23 women enrolled completed baseline injections and returned for the 4-week follow-up. There was no significant difference at 4 weeks in the change in brow height between the sides that received deep versus shallow BoNT-A injection. CONCLUSION: Because of the diffusion of the BoNT-A between muscle layers, the eyebrow depressor muscles cannot be accurately targeted with deep injection into the muscle belly for correction of eyebrow height discrepancies.

Quantitative measurement of evolution of postparetic ocular synkinesis treated with botulinum toxin type A.

BACKGROUND: The Sunnybrook Facial Grading System is considered one of the best scales available to grade facial motility and postparetic synkinesis. To measure facial landmarks and movement excursion, a new software, the Facial Assessment by Computer Evaluation, has been proposed. The aim of this study was to quantify eye synkinesis improvement after botulinum toxin type A injections using the new software and to compare this method with the Sunnybrook grading system. METHODS: The study included 40 injection sessions on 29 Caucasian outpatients with facial synkinesis. Before and 2 weeks after the injection, patients were evaluated using the Italian version of the Sunnybrook system. Eyelid fissure size at rest, during lip puckering, and while smiling was measured with the new software. RESULTS: After botulinum infiltration, the Sunnybrook grading system showed a global facial improvement with reduction of synkinesis and increase of static and dynamic symmetry. The Facial Assessment software detected an increase of ocular fissure measure at rest, during lip puckering, and especially during smiling, and the improvement was positively correlated with initial asymmetry. A single point of the Sunnybrook system synkinesis score corresponded to a mean difference of 0.77 mm during smiling and 1.0 mm during lip puckering. CONCLUSIONS: The Facial Assessment by Computer Evaluation measure allowed the authors to quantify the improvement of eye synkinesis after botulinum toxin type A injection. The Sunnybrook Facial Grading System provided an immediate instrument with which to monitor treatment in routine clinical practice, whereas the Facial Assessment system gave a more accurate quantitative assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.