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

A Combined Approach of Facial Neuromuscular Rehabilitation and Surgical Reconstruction in the Remediation of Facial Palsy: A Multidisciplinary Team Approach

Facial neuromuscular rehabilitation (fNMR) is an evidence-based practice for the treatment of peripheral facial palsy (PFP). Surgical reconstruction can be indicated for patients who demonstrate poor or no recovery to support symmetry, function, and aesthesis. There is paucity of research demonstrating the therapeutic benefit of a multidisciplinary team (MDT) in facial recovery of this specific subpopulation of patients. This article will outline the role of specialist facial therapy in the remediation of PFP, focusing on those who undergo surgical reconstruction to optimize their facial recovery. Case studies are used to demonstrate surgical and therapeutic outcomes as well as the results of a patient survey conducted for a service evaluation. We discuss the role of the MDT in supporting recovery as well as the role of targeted fNMR. The term fNMR is often used interchangeably with facial therapy or facial rehabilitation. We will refer to fNMR as a technique of facial rehabilitation.We aim to demonstrate that an MDT approach to the treatment of people with facial palsy provides positive outcomes for this surgical population and that future research would be beneficial to support this service delivery model.

Chronic Facial Paralysis Treated With Non-absorbable APTOS Barbed Threads: A Case Report With Anatomic Considerations

Chronic paralysis of the facial nerve leads to degenerative facial muscle and surrounding soft tissue alterations on the involved side, making the affected patients seem older than their actual age. Moreover, contralateral facial hypertrophy worsens facial asymmetry. Correction of the drooping or wrinkled face due to aging, trauma, or other pathology has been successfully treated with the thread-lifting technique. Here, we present the case report of a 23-year-old female patient suffering from oncologic post-surgery complications associated with chronic facial nerve paralysis. She also suffered from old and new cerebellar syndromes on the right side and lesions of the oculomotor, trochlear, and abducens nerves. Based on the patient history, the condition was treated under local anesthesia by the use of APTOS minimally invasive threads with barbs made from non-absorbable material. Correction and sculpting of the affected cheek area were performed by insertion of a light lift needle, and lifting of the superficial fat pads was secured by subdermal insertion of the light lift thread method. The jowl area was lifted by the superficial insertion of both types of threads. As a result, we significantly improved facial symmetry at rest, a more symmetric smile, a lifted corner of the mouth, and an anatomically sculpted cheek appearance.

Hyaluronic Acid-based Fillers for Facial Rehabilitation in Inherited Neuropath

Charcot-Marie-Tooth (CMT) disease is the most prevalent inherited neuromuscular disorder. It commonly leads to various musculoskeletal deformities, profoundly impacting the quality of life. The present case report explores the often under-recognized body image dissatisfaction in CMT, highlighting the potential benefits of a multidisciplinary approach to enhance aesthetic satisfaction. We present a case of a 54-year-old woman with CMT, who experienced chronic facial asymmetry, significantly impairing her quality of life. Seeking cosmetic enhancement, she underwent two sessions of facial treatment using hyaluronic acid-based fillers. The first session focused on correcting right mandibular hypoplasia and other facial asymmetries, whereas the second session focused on enhancing perioral aesthetics. The treatment resulted in significant aesthetic improvements, as demonstrated by high ratings in both the Physician Global Aesthetic Improvement Scale and the Subject Global Aesthetic Improvement Scale. Besides, there was a marked reduction in lip corner asymmetry, the patient's primary concern. The role of hyaluronic acid fillers in facial aesthetic enhancement is well established, and their application in the context of CMT is a promising under-investigated field, to our knowledge. This case study highlights the importance of considering body image in CMT patients and suggests that minimally invasive aesthetic procedures can be a valuable addition to the multidisciplinary care of patients with inherited neurological disorders. Despite being a single-case study, the significant improvement in the patient's aesthetic satisfaction requires further research in this field.

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.

Role of Robotics in Neuromodulator and Filler Injections of Face

In recent years, robots have been increasingly used in various fields of medicine, including surgery, dentistry, and ophthalmology. One of the newest and most promising applications of robotic technology in medicine is in the field of facial aesthetics, particularly in the injection of facial fillers and neuromodulators. While facial injections have traditionally been performed manually by trained physicians and nurses, the introduction of robots has the potential to revolutionize the field, offering a range of potential benefits, including increased precision, accuracy, and consistency of results. However, the significant disadvantages of robots are high cost, lack of flexibility and personal touch, limited experience, and risk of injury due to malfunction.

Optimizing the results of facial animation surgery: Botulinum toxin injection into free functional gracilis flap transfer

Although neuromuscular gracilis transplantation is the best choice for facial reanimation in patients with congenital or inveterate palsy, the results are not completely satisfactory. Ancillary procedures developed to achieve better symmetry of the smile and reduce the hypercontractility of the transplanted muscle have been reported. However, the intramuscular injection of botulinum toxin has not been described for this purpose. Patients undergoing gracilis injections of botulinum toxin after facial reanimation surgery between September 1, 2020, and June 1, 2022, were retrospectively enrolled in this study. We collected photographs taken before and 20-30 days after injection and compared the symmetry of the face using software. Nine patients with a mean age of 23.56 years (range, 7-56 years) were enrolled. Reinnervation of the muscle was provided by the contralateral healthy facial nerve via a sural cross-graft (four patients), by the ipsilateral masseteric nerve (three cases), and by the contralateral masseteric and facial nerve (two). Using Emotrics software, we identified differences in the commissure excursion discrepancy of 3.82 mm, the smile angle discrepancy of 0.084°, and the dental show discrepancy of 1.49 mm; the average difference in the commissure height deviation was 2.26 mm (P = 0.02), and those in the upper- and lower-lip height deviation were 1.05 mm and 1.49 mm, respectively. Gracilis injection of botulinum toxin after gracilis transplantation is a safe and feasible procedure that could be applicable to all patients with asymmetric smiles related to excessive transplant contraction. It yields good esthetic results with little to no related morbidity.

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.

Bell felcinin viral patojenitesi ve tedavi olarak botulinum toksin tip A kullanımı

Bell'in felci, kraniyal sinir VII'nin iltihaplanmasının ortak adıdır. Kendine özgü genikulat ganglion iltihabı idiyopatiktir ve hemifasiyal felce neden olur. Bu felçten muzdarip olan hastaların semptomları 3 hafta ile 3 ay arasında kaybolabilir. Yüz felci devam eden bazı hastalar için botulinum toksin tip A etkili bir tedavi olabilir. Kas felcinin şiddetine göre botoksun yanı sıra ameliyat, steroid ve antiviral tedavi gibi farklı tedaviler sunulabilir. Bu derleme makalesinin amacı, viral patojenlerin fasiyal sinir iltihabının aktivasyonu ile olası ilişkisine ve Bell felçli hastaların tedavi olarak botoks tip-A'dan nasıl yararlanabileceğine dalmaktır.

Botulinum Toxin Type A: Adverse Events and Management

Aesthetic medicine is witnessing an increasing exploitation of all the procedures. The demand has never been higher than it is today. The number of practitioners is also increasing year by year. Consequently complications and other kinds of related troubles and procedures are also rising. Never like today is fundamental, in case of troubles, how to properly manage with the most frequent issues. In aesthetic medicine field, botulinum toxin procedures are the safest. Lot of patients are worried about botulinum toxin despite the available scientific literature. Rare short-term complications are observed. In the most of cases, nothing severe occurs if the international recommendations and the most recent guidelines are closely followed, the majority of them are injection related. This study is a review of rare or common problems that can occur and how to manage or solve the situations.

Alterations in Integumental Facial Dimensions after Orthodontic Treatment

BACKGROUND

It is documented that the facial profile changes, morphology changes, and continued facial growth in early adults and late adolescents.

AIMS

The present trial was aimed to quantitatively assess the changes in facial growth from adolescents to adults.

MATERIALS AND METHODS

In the present study, 16 facial distances (transverse) and craniocaudal facial distances were measured, and growth changes were assessed. The collected data were subjected to statistical evaluation, and the results were formulated.

RESULTS

Upper face width was statistically significantly increased in males than females from posttreatment to recall with the P < 0.0001. The decrease in outer canthus was seen in females as compared to males, which was statistically significant with the P < 0.0001. An increase in mouth width was seen in both males and females with higher in females.

CONCLUSION

The present study showed an increase in facial dimensions in both genders with age where transverse changes were higher than the craniocaudal alterations.

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.