Botulinum Toxin in the Treatment of Facial Paralysis

Consensus Among International Facial Therapy Experts for the Management of Adults with Unilateral Facial Palsy: A Two-Stage Nominal Group and Delphi Study

Background: Nonsurgical rehabilitation of unilateral peripheral facial palsy (FP) varies globally with controversy regarding best practice. Objective: To develop facial therapist consensus regarding what should be included or excluded in rehabilitation of adults with FP of any etiology. Three clinical presentations: flaccid, paretic and synkinetic, were separately considered. Methodology: A two-stage study was conducted: a nominal group technique (NGT) to develop a questionnaire plus Delphi study. Delphi participants were recruited worldwide, through an experience-based inclusion questionnaire. The final Delphi questionnaire included 166 items for each clinical presentation covering assessment, outcome measures, and interventions, for example, education, eye care, neuromuscular retraining, and electrical modalities. Inclusion/exclusion agreement was set at 80%, indicating participant consensus. Items reaching 70-79% were deemed "near-included/near-excluded." Results: Averaged across all presentations, 24.9% of the 166 items were included, (e.g., Sunnybrook Facial Grading System, patient education and neuromuscular retraining), 26.9% of the 166 items were excluded, (e.g., gross strengthening and electrical stimulation); 48.2% were neither included nor excluded. Conclusion: This study brings together the global community's expertise as a first step toward establishing best practice for specialist facial therapy. It is hoped this will guide clinical decision making, advance research, and optimize patient outcomes in this challenging field.

Task force of the Brazilian Society of Otology - evaluation and management of peripheral facial palsy

OBJECTIVE

To review key evidence-based recommendations for the diagnosis and treatment of peripheral facial palsy in children and adults.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on peripheral facial palsy were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 main parts: (1) Evaluation and diagnosis of facial palsy: electrophysiologic tests, idiopathic facial palsy, Ramsay Hunt syndrome, traumatic peripheral facial palsy, recurrent peripheral facial palsy, facial nerve tumors, and peripheral facial palsy in children; and (2) Rehabilitation procedures: surgical decompression of the facial nerve, facial nerve grafting, surgical treatment of long-term peripheral facial palsy, and non-surgical rehabilitation of the facial nerve.

CONCLUSIONS

Peripheral facial palsy is a condition of diverse etiology. Treatment should be individualized according to the cause of facial nerve dysfunction, but the literature presents better evidence-based recommendations for systemic corticosteroid therapy.

[Five-year follow-up after neurosurgery complicated by facial neuropathy]

BACKGROUND

Botulinum toxin A (BTA) injections are effective for facial neuropathy. However, there is insufficient number of studies devoted to long-term management of these patients.

OBJECTIVE

To evaluate the effectiveness and safety of BTA therapy in patients with facial neuropathy after neurosurgical interventions.

MATERIAL AND METHODS

The study included 86 patients with facial neuropathy after surgical treatment of posterior cranial fossa and cerebellopontine angle tumors. All ones were divided into 2 groups: group I (main) - 57 patients with BTA prescribed early after facial nerve injury, group II (control) - 29 people undergoing exercise therapy, as well as special exercises and acupressure of painful muscle cords. The Sunnybrook Facial Grading Scale (SFGS) was used to assess facial symmetry and synkinesis, the Facial Disability Index (FDI scale) - to assess the quality of life. Overall duration of the study was 5 years (control points: 6 months, 1, 2, 3 and 5 years).

RESULTS

The SFGS scores after 1, 2, 3 and 5 years were significantly better in the main group (resting symmetry p<0.01, voluntary movement symmetry p<0.01, synkinesis p<0.01, general condition of facial muscles p<0.01). Scores of physical and social functioning were significantly higher in the main group after 1 (p<0.01), 2 (p<0.01), 3 (p<0.01) and 5 years (p<0.01) after surgery. There was no need to change BTA dosage over 5 years. Thus, this form of BTA may be the most effective for synkinesis of facial muscles.

CONCLUSION

Correction of synkinesis caused by facial neuropathy requires long-term follow-up and long-term treatment. BTA is effective and may be recommended for long-term treatment of these patients.

Botulinum toxin treatment of the buccinator muscle facial synkinesis: A systematic review

BACKGROUND

The purpose of this review is to provide an overview of the available literature assessing the treatment of botulinum toxin injections for the treatment of synkinesis of the buccinator muscle in patients with peripheral facial palsy (PFP).

MATERIALS AND METHODS

A multi database search was performed, including the following databases: Pubmed, Medline, Embase, and the Cochrane Library. Each database was searched from its earliest date until 8 June 2023. The following outcome measures were extracted from the articles when available: subjective, somatic, and psychological effects on the patients and objective outcomes such as the House-Brackmann, Sunnybrook and Sydney scores. The methodological quality of the included studies was rated using the Newcastle-Ottawa scale for nonrandomised trials.

RESULTS

The primary literature search generated 37 articles. After removing duplicates, 25 articles remained for abstract appraisal, of which 20 underwent full-text appraisal, resulting in 3 studies for analysis. All of these studies showed (significant) improvement in synkinesis either measured using the Synkinesis Assessment Questionnaire or subjectively measured by asking treated patients.

CONCLUSION

The available literature supports the finding that botulinum toxin treatment of the buccinator muscle could be a welcome addition to facial synkinesis treatment and could significantly improve patient outcomes. In future studies, the efficacy of EMG-guided buccinator injections, optimal dose, and a validated measuring method could be beneficial in optimising treatment for patients with a PFP and synkinesis.

Mechanism and clinical use of botulinum neurotoxin in head and facial region

PURPOSE

Botulinum neurotoxin (BoNT) is a biological toxin produced by Clostridium botulinum. BoNT is a potent toxin extensively used in therapeutic interventions. This review provides an updated overview of the mechanisms of action and clinical applications of BoNT in head and facial region.

STUDY SELECTION

MEDLINE/PubMed searches were conducted using the terms "botulinum neurotoxin" and "dentistry" along with a combination of other related terms. In addition, studies were manually selected from reference lists of the selected articles.

RESULTS

The Food and Drug Administration in the United States initially approved BoNT to treat strabismus, blepharospasm, and hemifacial spasms. The use of BoNT in dermatology and cosmetics has been widely established and has created a revolution in these fields. Over the years, its applications in various medical specialties have expanded widely. Owing to its safety, efficacy, and long duration of action, it is well-accepted by patients. BoNT/A and BoNT/B are widely used in clinical practice. Several off-label uses of BoNT in the dental fraternity have yielded promising results. We have elaborated on the speculated mechanism of action, dosage, effective sites of injection, and adverse effects of each therapeutic application. The various clinical indications for BoNT include bruxism, myofascial pain, temporomandibular joint dislocation, hemifacial pain, orofacial dystonia, facial paralysis, chronic migraine, and trigeminal neuralgia.

CONCLUSIONS

BoNT is a safe treatment that can be used effectively, provided that the clinician has adequate knowledge regarding the mechanism, injection techniques, and local and systemic side effects and that it is administered cautiously and purposefully.

The evolution of facial reanimation techniques

This review article provides an updated discussion on evidence-based practices related to the evaluation and management of facial paralysis. Ultimately, the goals of facial reanimation include obtaining facial symmetry at rest, providing corneal protection, restoring smile symmetry and facial movement for functional and aesthetic purposes. The treatment of facial nerve injury is highly individualized, especially given the wide heterogeneity regarding the degree of initial neuronal insult and eventual functional outcome. Recent advancements in facial reanimation techniques have better equipped clinicians to approach challenging patient scenarios with reliable, effective strategies. We discuss how technology such as machine learning software has revolutionized pre- and post-intervention assessments and provide an overview of current controversies including timing of intervention, choice of donor nerve, and management of nonflaccid facial palsy with synkinesis. We highlight novel considerations to mainstay conservative management strategies and examine innovations in modern surgical techniques with a focus on gracilis free muscle transfer. Innervation sources, procedural staging, coaptation patterns, and multi-vector and multi-muscle paddle design are modifications that have significantly evolved over the past decade.

Is It Worth Using Botulinum Toxin Injections for the Management of Mild to Moderate Blepharoptosis?

BACKGROUND

Mild ptosis can be aesthetically displeasing for patients, especially in unilateral cases. However, some patients do not desire to undergo a surgical repair. Botulinum toxin injection might be an option in these cases.

OBJECTIVES

The authors sought to objectively examine the effects of botulinum neurotoxin A (BoNT-A) injection into the orbicularis oculi muscle in the management of blepharoptosis.

METHODS

In this prospective study, 8 patients with mild to moderate ptosis received application of BoNT-A in the pretarsal orbicularis oculi muscle. Standardized photographs were obtained at baseline and 2, 4, and 24 weeks. Digital image analysis software (Image J) was employed for objective analysis. Primary outcomes were the margin reflex distance-1 and qualitative changes on a 4-point scale.

RESULTS

A significant increase in the margin reflex distance-1 on the treated side (baseline: 2.00 ± 1.13 mm; week 2: 2.52 ± 1.13 mm; P = 0.003) and a significant reduction (baseline: 3.23 ± 0.92 mm, week 2: 3.07 ± 0.96; P = 0.0268) on the contralateral eyelid were observed at week 2. After 24 weeks, the effect of BoNT-A diminished, and no significant difference from baseline was observed in either eyelid. Subjectively, 87.5% of patients reported improvement in their eyelid ptosis.

CONCLUSIONS

Botulinum toxin injection in the pretarsal orbicularis oculi muscle can be an option to temporarily manage ptosis in patients who do not desire to undergo a surgical procedure. This alternative treatment can also be employed to manage temporary ptosis induced by botulinum toxin diffusion to the levator aponeurosis.

LEVEL OF EVIDENCE: 4

Epineurectomy of Facial Nerve Trunk for Refractory Oral-Ocular and Oculo-Oral Synkinesis Following Bell Palsy

BACKGROUND

Synkinesis is a common sequelae after incomplete recovery from Bell palsy. Current first-line treatments include botulinum toxin injection and physical therapy. However, patients unresponsive to these treatments may require further surgery. Various surgical treatments have been reported, but no consensus has been reached for the optimal surgery. In a guinea pig model of synkinesis, the facial nerve trunk (FNT) was observed using a scanning electron microscope. Based on the results of scanning electron microscope and clinical ultrasonography, the authors chose FNT as the therapeutic target.

METHODS

The authors performed epineurectomy of FNT for 11 patients with refractory oral-ocular and oculo-oral synkinesis under abnormal muscle response and facial electromyography monitoring. The postoperative assessments at 1 year were conducted using Sunnybrook Facial Grading System and Facial Disability Index scale. Furthermore, the epineurium excised during the operation was collected as the specimen and submitted for histopathological examination; the cadaveric FNT served as the control group.

RESULTS

The follow-up results showed significant relief from synkinesis (4.91 ± 0.37 versus 10.18 ± 0.64, P < 0.01), improvement of physical (84.55 ± 1.96 versus 73.18 ± 3.65, P < 0.01) and social functions (77.09 ± 3.24 versus 61.82 ± 6.28, P < 0.01), with no worsening of facial paralysis in the patients. The histopathological examination revealed many nerve fibers in the epineurium, suggesting that FNT was the area of aberrant axon regeneration.

CONCLUSIONS

Epineurectomy of FNT is a safe and effective surgical remedy. It can be considered as a surgical option for patients with refractory oral-ocular and oculo-oral synkinesis following Bell palsy.

Cost of peripheral facial palsy treatment with Botulinum Toxin type A

INTRODUCTION

Facial palsy (FP) is one of the most common neuropathies. Overall, 15%-30% of patients develop chronic sequelae. Several studies support the use of botulinum toxin A (BoNT-A) in the treatment of FP sequelae. No studies have analyzed the cost of treating FP with BoNT-A.

METHODS

A retrospective review of data from all clinical records of consultations and procedures that took place at the FP Treatment Unit clinic throughout 2017. Type of BoNT-A used, total dose used, unilateral or bilateral injection, date of consultation, and gender were collected. The price of expendable materials, BoNT-A, and the 2017 salary scale was obtained to establish costs.

RESULTS

During 2017, 605 clinical procedures were conducted in 240 patients. The mean number of procedures was 2.5 (0.80). The average time between procedures was 124(28.72) days. The total annual cost was 34.155,10€. The average annual cost of BoNT-A for each procedure was 39,93€, and the total annual cost of BoNT-A was 24.160,58€. On average, more units of IncotoxA were injected. This difference is not reflected in the final cost of each BoNT-A. For patients who achieved treatment stability, the average annual cost per patient was 106,6€ (OnatoxA) and 100,6€ (IncotoxA).

CONCLUSION

In our unit, treatment with BoNT-A in FP sequelae had an average annual cost of 124,31€ per patient, requiring a visit to the hospital to receive treatment every 124 days. Given the functional and quality of life improvements, we should consider that it is a beneficial treatment at an acceptable cost.

Adverse Events Associated With Botox as Reported in a Food and Drug Administration Database

BACKGROUND

Botulinum toxin treatment is the most frequently performed noninvasive cosmetic procedure performed in the USA. Because of its widespread use, an analysis of the adverse event (AE) profile of Botox injections is needed.

METHODS

The FDA Adverse Event Report System was queried using an online web-based tool to determine the top 15 adverse events reported for four Botox brand names: Botox/Botox Cosmetic, Dysport, and Xeomin. The proportional reporting ratios (PRR) and relative odds ratios (ROR) were determined. A literature review was performed for eight AEs of clinical significance: eyelid/eyebrow ptosis, asthenia, muscular weakness, facial paresis, dysphagia, botulism, and death.

RESULTS

Botox/Botox Cosmetic had 38367 AEs. Dysport had 3582 AEs. Xeomin had 1405 AEs. All drugs with reported cases of eyelid and eyebrow ptosis had significant PRR and ROR values. The PRR and ROR values for asthenia were not significant in any of the drugs and only reached significance for Dysport for muscular weakness and dysphagia. Both Botox/Botox Cosmetic and Dysport had elevated PRRs and RORs for facial paresis and botulism. While all drugs had at least one reported case of death related to Botox injection use, none of the PRR or ROR values were significant.

CONCLUSION

Known AEs for Botox injection use include eyelid/brow ptosis and muscular weakness. Feared but rare complications of Botox injection use include dysphagia, botulism, and possibly death, owing to systemic spread of the toxin. This is the first study to analyze the AE data reported to the FDA on Botox injection use.

EBM LEVEL

III.

Facial paralysis: timing of repair and management of the nonflaccidly paralyzed face

PURPOSE OF REVIEW

To explore recent advances in therapeutic interventions for nonflaccid facial paralysis (NFFP), including new evidence for surgical and nonsurgical treatments. Timing of treatment is also discussed, along with possible future treatments.

RECENT FINDINGS

NFFP remains a difficult disease to treat. Chemodenervation with botulinum toxin remains a first-line treatment to suppress aberrant and antagonistic movements during voluntary use of muscles. More permanent treatments such as selective neurectomy, myectomy, and nerve and muscle transfers have been shown to offer promising results for the nonflaccidly paralyzed face.

SUMMARY

NFFP is commonly seen in patients who have incomplete recovery from facial paralysis, and carries high psychosocial morbidity. A large array of treatments have been described in the literature, both procedural and nonprocedural. Both treatment type and timing are important in optimal patient recovery.

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

Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression. Among therapeutical approaches, use of Botulinum toxin type A (BoNT-A) on the nonparalyzed side has shown promising results and improvement of quality of life. Nevertheless, the correct technique is paramount, since over-injection of the muscles can result in lack of function, leading to a "paralyzed" appearance, and even worse, functional incompetence, which may cause greater distress to patients. Therefore, the objective of this article is to provide a practical guideline for botulinum toxin use in facial palsy. To this aim, adequate patient assessment, BoNT-A choice, injection plan and dosage, and injection techniques are covered.

The Treatment of Facial Asymmetry with Botulinum Toxin: Current Concepts, Guidelines, and Future Trends

This article will describe facial asymmetry secondary to facial nerve paralysis (FNP), and review current concepts, guidelines, and future trends. Despite the increasing use of botulinum toxin (BoNTA) in treating FNP, ideal dosage, timing, and additional therapies are not unequivocally established. Facial asymmetry significantly impacts quality of life (QOL) by strongly affecting self-perception and social interactions; injectables may mediate great clinical improvement. This article provides practical guidelines for the use of BoNTA and provides schemes for accurate assessment and documentation. A systematic, stepwise approach is recommended with methodical assessment, meticulous placement, conservative dosage, and careful follow-up. Future trends include the potential use of newly developed toxins, muscle modification with fillers, improved imaging techniques, and targeted QOL studies. Hopefully, a growing number of aesthetic injectors may become technically proficient and join multidisciplinary teams for managing FNP.

Effect of pulse waveforms on movement amplitudes and perceived discomfort in electric muscle stimulation in unresolved facial nerve palsy

Studies on the effects of the pulse waveform used in electrical muscle stimulation on the activations and perceived discomfort of the waveform have been mainly executed on limb muscles with variable results, however, knowledge of these effects on facial muscles is currently lacking. We studied two waveforms, square wave and sinusoidal wavelet, for the activation of the frontalis muscle in 9 individuals with unresolved facial nerve palsy. Both waveforms produced a movement that was greater in amplitude compared with the maximal voluntary movement of the affected side in 8 participants and at least as great as the healthy side's maximal voluntary movement in 4 participants. Both waveforms were equally successful in producing movements, and there was no significant difference in perceived discomfort ratings between the two waveforms. These findings will be useful for the future development of neuroprosthetic applications for reanimating facial muscles using electrical stimulation. Trial registration: ClinicalTrials.gov NCT03496025, registration date March 19, 2018.

Facial paralysis: Clinical practice guideline of the Spanish Society of Otolaryngology

Bell's palsy is the most common diagnosis associated with facial nerve weakness or paralysis. However, not all patients with facial paresis/paralysis have Bell's palsy. Other common causes include treatment of vestibular schwannoma, head and neck tumours, iatrogenic injuries, Herpes zoster, or trauma. The approach to each of these conditions varies widely. The purpose of this guideline is to provide clinicians with guidance on the treatment and monitoring of patients with different causes of facial paralysis. We intend to draft a practical guideline, focusing on operationalised recommendations deemed to be useful in the daily management of patients. This guideline was promoted by the Spanish Society of Otolaryngology and developed by a group of physicians with an interest in facial nerve disorders, including at least one physician from each Autonomous Community. In a question and answer format, it includes 56 relevant topics related to the facial nerve.

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.

Facial muscle reanimation by transcutaneous electrical stimulation for peripheral facial nerve palsy

Reanimation of paralysed facial muscles by electrical stimulation has been studied extensively in animal models, but human studies in this field are largely lacking. Twenty-four subjects with a peripheral facial nerve palsy with a median duration of three years were enrolled. We studied activations of four facial muscles with electrical stimulation using surface electrodes. In subjects whose voluntary movement was severely impaired or completely absent, the electrical stimulation produced a movement that was greater in amplitude compared with the voluntary effort in 10 out of 18 subjects in the frontalis muscle, in 5 out of 14 subjects in the zygomaticus major muscle, and in 3 out of 8 subjects in the orbicularis oris muscle. The electrical stimulation produced a stronger blink in 8 subjects out of 22 compared with their spontaneous blinks. The stimulation could produce a better movement even in cases where the muscles were clinically completely paretic, sometimes also in palsies that were several years old, provided that the muscle was not totally denervated. Restoring the function of paralysed facial muscles by electrical stimulation has potential as a therapeutic option in cases where the muscle is clinically paretic but has reinnervation.

Contemporary Review and Case Report of Botulinum Resistance in Facial Synkinesis

BACKGROUND

Botulinum resistance poses significant treatment challenges for both patients and healthcare practitioners. We first present a case highlighting botulinum resistance in a patient who failed to respond to alternative formulations but who responded remarkably to incobotulinum toxinA, an identical toxin free of complexing proteins. Secondly, we provide a treatment algorithm and a review of the literature detailing clinical and immunochemical botulinum resistance.

RESULTS

Patients with botulinum resistance show a predisposition to failure on subsequent injections and possess a propensity toward neutralizing and nonneutralizing antibody development. The mechanisms of resistance are not entirely understood but thought to be secondary to an immunologic response. Risk factors for resistance include higher botulinum doses, more frequent injections, and high total lifetime dosage. Patients may still respond to other botulinum formulations or subtypes; however, this effect may be temporary.

CONCLUSION

This case report describes a patient who responded to incobotulinum toxinA after failing treatment with the identical toxin compounded with buffer proteins, ultimately supporting the possibility of immune-mediated resistance to the surrounding proteins and not the toxin itself. Often, impending treatment resistance is preceded by a poor or limited clinical response. Antibody testing is not indicated because it is neither sensitive nor specific and does not change clinical practice. Initially, higher doses of botulinum may overcome resistance without increasing treatment frequency, and side effects are far less common in those with clinical resistance. If higher dosages fail to produce a response, alternative botulinum formulations or subtypes can be considered. Laryngoscope, 129:2269-2273, 2019.

Facial Rehabilitation: Evaluation and Treatment Strategies for the Patient with Facial Palsy

This article describes the most widely used clinician-graded and patient-reported outcome measures, and describes facial rehabilitation strategies for acute and chronic facial palsy, and rehabilitation following dynamic facial reanimation surgery. The multimodality rehabilitation of the facial palsy patient is determined by the extent of facial nerve injury, specific functional deficits, the presence of synkinesis, and the patient's individual goals. Appropriate intervention, including patient education, soft tissue mobilization, neuromuscular reeducation, and chemodenervation, decreases facial tension and improves facial muscle motor control, physical function, facial expression, and quality of life.

Components of the alternative complement pathway in patients with psoriasis

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease. Adipose tissue plays important roles in the events that regulate body metabolism. This study determined the levels of complement 3 ( C3), acylation-stimulating protein (ASP), and adipsin, which take part in the alternate complement pathway, and are synthesized in and secreted by adipose tissue.

METHODS

Thirty-two patients with psoriasis were matched with 22 controls in terms of age, sex, body mass index, and lipid profiles. Serum C3, ASP, and adipsin levels were measured in both groups.

RESULTS

The serum C3 level was higher and ASP and adipsin levels were lower in the patient group, but these differences were not significant (p = 0.708, p = 0.628, and p = 0.218, respectively). ASP and adipsin levels were correlated positively in patients with psoriasis (p = 0.029).

CONCLUSION

To our knowledge, this study is the first to evaluate ASP and adipsin levels in patients with psoriasis. The roles of ASP and adipsin in the etiopathogenesis of psoriasis are unclear. Although not statistically significant, the lower ASP and adipsin levels in the patient group suggest a potential anti-inflammatory role of these proteins in psoriasis. Further studies should examine the relationships between ASP/adipsin and psoriasis.

Dermatobia hominis misdiagnosed as abscesses in a traveler returning from Brazil to Denmark

We present the case of a 62-year-old woman that consulted us for two boil-like lesions on her thighs after returning from a trip to São Paulo, Brazil, where she had swum in a freshwater lake. After consulting three specialist doctors and undergoing two antibiotic treatments, she was diagnosed with furuncular myiasis caused by Dermatobia hominis. The parasites were excised with no complications.

[Facial nerve injury in neurosurgery: a rehabilitation potential of botulinum therapy]

Surgical treatment of posterior cranial fossa and cerebellopontine angle tumors is associated with a risk of facial nerve dysfunction. The causes for facial muscle paresis include nerve compression by the tumor, destruction of the nerve structure by the tumor growing from nerve fibers, nerve injury during surgical removal of the tumor, etc. The first 3 months after facial nerve injury are a potential therapeutic window for the use of botulinum toxin type A (BTA). During this period, the drug is introduced both in the healthy side to improve the facial symmetry at rest and during mimetic movements and in the affected side to induce drug-induced ptosis. Post-paralytic syndrome develops 4-6 months after facial nerve injury. At this stage, administration of BTA is also an effective procedure; in this case, drug injections are performed on the affected side at small doses and symmetrically on the healthy side at doses doubling those for the affected side. BTA injections are mandatory in complex treatment of facial muscle paralysis.

Facial palsy: what can the multidisciplinary team do?

The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice.

Surgical treatment of synkinesis between smiling and eyelid closure

Synkinetic movements are common among patients with incomplete recovery from facial palsy, with reported rates ranging from 9.1% to almost 100%. The authors propose the separation of the neural stimulus of the orbicularis oculi from that of the zygomatic muscular complex to treat eyelid closure/smiling synkinesis. This technique, associated with an anastomosis between the masseteric nerve and a central branch of the facial nerve, as well as with the use of a cross-facial nerve graft, resolves most of the spasms of the midface musculature, leading to a more relaxed tone when the mimic muscle is at rest and enhancing muscle excursion during voluntary and spontaneous smiling. Between 2011 and 2016, 18 patients affected by segmental paresis of the middle of the face underwent surgical treatment at the Maxillofacial Surgery Department of the San Paolo Hospital (Milan, Italy). Of these patients, 72.22% of cases with hypertone obtained partial to complete relaxation. Synkinesis was completely resolved in 83.33% of cases, and a significant improvement in facial movement was achieved in all patients. Neurorrhaphy of the masseteric nerve and the central branch of the facial nerve appears to produce favorable results. These initial data should be confirmed by further studies.