Treatment Patterns and Outcomes in Botulinum Therapy for Patients With Facial Synkinesis.

IMPORTANCE: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life. OBJECTIVE: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center. INTERVENTION: Onabotulinum toxin A treatment of facial synkinesis. MAIN OUTCOMES AND MEASURES: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment. RESULTS: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis. CONCLUSION AND RELEVANCE: Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesis. LEVEL OF EVIDENCE: 3.

Outcomes of Buccinator Treatment With Botulinum Toxin in Facial Synkinesis.

IMPORTANCE: The buccinator, despite being a prominent midface muscle, has been previously overlooked as a target in the treatment of facial synkinesis with botulinum toxin. OBJECTIVE: To evaluate outcomes of patients treated with botulinum toxin to the buccinator muscle in the setting of facial synkinesis. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study of patients who underwent treatment for facial synkinesis with botulinum toxin over multiple treatment cycles during a 1-year period was carried out in a tertiary referral center. INTERVENTIONS: Botulinum toxin treatment of facial musculature, including treatment cycles with and without buccinator injections. MAIN OUTCOMES AND MEASURES: Subjective outcomes were evaluated using the Synkinesis Assessment Questionnaire (SAQ) prior to injection of botulinum toxin and 2 weeks after treatment. Outcomes of SAQ preinjection and postinjection scores were compared in patients who had at least 1 treatment cycle with and without buccinator injections. Subanalysis was performed on SAQ questions specific to buccinator function (facial tightness and lip movement). RESULTS: Of 84 patients who received botulinum toxin injections for facial synkinesis, 33 received injections into the buccinator muscle. Of the 33, 23 met inclusion criteria (19 [82.6%] women; mean [SD] age, 46 [10] years). These patients presented for 82 treatment visits, of which 44 (53.6%) involved buccinator injections and 38 (46.4%) were without buccinator injections. The most common etiology of facial paralysis included vestibular schwannoma (10 [43.5%] participants) and Bell Palsy (9 [39.1%] participants). All patients had improved posttreatment SAQ scores compared with prebotulinum scores regardless of buccinator treatment. Compared with treatment cycles in which the buccinator was not addressed, buccinator injections resulted in lower total postinjection SAQ scores (45.9; 95% CI, 38.8-46.8; vs 42.8; 95% CI, 41.3-50.4; P = .43) and greater differences in prebotox and postbotox injection outcomes (18; 95% CI, 16.2-21.8; vs 19; 95% CI, 14.2-21.8; P = .73). Subanalysis of buccinator-specific scores revealed significantly improved postbotox injection scores with the addition of buccinator injections (5.7; 95% CI, 5.0-6.4; vs 4.1; 95% CI, 3.7-4.6; P = .004) and this corresponded to greater differences between prebotulinum and postbotulinum injection scores (3.3; 95% CI, 2.7-3.9; vs 2.0; 95% CI, 1.4-2.6; P = .02). The duration of botulinum toxin effect was similar both with and without buccinator treatment (66.8; 95% CI, 61.7-69.6; vs 65.7; 95% CI, 62.5-71.1; P = .72). CONCLUSIONS AND RELEVANCE: The buccinator is a symptomatic muscle in the facial synkinesis population. Treatment with botulinum toxin is safe, effective and significantly improves patient symptoms. LEVEL OF EVIDENCE: 3.

Innovations in nasal valve surgery.

PURPOSE OF REVIEW: This article reviews current practices in nasal valve repair and highlights recent innovations in the medical literature. RECENT FINDINGS: A surgeon's choice regarding a proper nasal valve repair technique depends heavily on the patient's site of obstruction. While classical maneuvers to improve the internal and external nasal valves have been employed for several decades, increasing understanding of lateral wall insufficiency and its role in nasal valve compromise has led to improvement of proposed methods for correcting the nasal valve. Radiofrequency-induced thermotherapy, the upper lateral strut graft, stairstep graft, and nasal valve lift techniques are described in detail. These four techniques offer innovative means of dealing with the challenge of nasal valve collapse resulting in nasal obstruction. SUMMARY: This review article provides an overview of the current practice in the field of nasal valve repair and summarizes recent technical advances in the field.

A community-based participatory research approach to developing the Harvest for Healthy Kids curriculum.

BACKGROUND: A diet rich in fruits and vegetables is associated with reduced risk of diet-related chronic diseases. However, fewer than half of children in the United States consume the recommended amount. OBJECTIVES: This article describes the community-based participatory research (CBPR) process used to develop the Harvest for Healthy Kids curriculum. METHODS: Harvest for Healthy Kids is a intervention research project designed to increase access to and intake of fruits and vegetables among preschoolers enrolled in Head Start. The curriculum is composed of eight kits, each focusing on a different fruit or vegetable. RESULTS: The Harvest for Healthy Kids curriculum was developed through an iterative process in which Head Start teachers were highly involved. The final product reflects the teachers' experiences using the curriculum and their suggestions for improving. CONCLUSIONS: The CBPR process used to develop the Harvest for Healthy Kids curriculum led to a product that is grounded in theory and practice.