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

Abstract

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 PARTICIPANTSThis 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 AssessmentQuestionnaire 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. RESULTSIn 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.

Long‐term therapy with botulinum toxin in facial synkinesis: Retrospective data analysis of data from 1998 to 2018

“…Several groups described an increase of BoNT dosage in patients with synkinetic defective healing and support our results 5,12,18,19 . Kollewe et al demonstrated an increase of BoNT dosage in 14% of the patients.…”

“…Nevertheless, Choi et al emphasised use of a lower dosages of OnaBoNT. There are several reports showing that higher amounts of OnaBoNT are well tolerated and are associated with higher satisfaction scores and more favourable outcome 12,20 . Amount of AboBoNT (68 units) was higher in our patients than reported elsewhere 20 .…”

“…In our patients, injection of both, synkinetic and non‐synkinetic side was favoured during long‐term therapy. Worldwide, treatment of both sides is the favoured method of therapy 1,12,20 …”

“…Several working groups previously reported about wide‐ranging effects of BoNT in facial synkinesis 4,12,13 . However, only few information exists on the injection patterns and the effects of the BoNT in the long‐term therapy.…”

Botulinum Toxin Type A to Improve Facial Symmetry in Facial Palsy: A Practical Guideline and Clinical Experience

“…Regardless of its etiology, idiopathic (Bell’s Palsy) or secondary facial nerve palsy, due to multiple etiologies such as Ramsey Hunt syndrome, infection, vascular, tumor resection and base of skull injuries, among others, manifests a unilateral peripheral facial nerve palsy which may lead to involuntary static and dynamic alterations of facial expression due to aberrant regeneration of fibers in the neural repair process in as many as 55.5% of patients with longstanding facial weakness [ 1 , 2 , 3 , 4 , 5 ]. The imbalance, static and dynamic, resulting from the muscular paralysis may not only jeopardize simple daily tasks such as articulation, eating and drinking, but is often cosmetically unacceptable to patients due to asymmetry, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression [ 6 , 7 ].…”