May 2021

Passive physiotherapy yielded no improvement. After 6 months, she experienced spontaneous improvement and the eyelid resumed normal functionality.

At around 48–49 years of age, she began undergoing BoNTA treatment of the upper third of the healthy side of her face, with good aesthetic outcomes, self-assessed as a 4 (‘much improved’) on GAIS. Ten years later, she underwent a surgical neck lift with results that were initially positive but began to deteriorate within ~2 years.

The patient started treatment at our center in July 2019, based on a full-face and neck approach using onabotulinumtoxinA (Table 2; Figure 2A). Repeat treatment using a similar injection pattern was undertaken in December 2019 and May 2020. Excellent results were achieved (Figure 2), particularly considering her advanced age. The patient was especially satisfied with the improvements in the lower third, mouth, and neck areas. She assessed the overall results on GAIS as a 5, representing a ‘very much improved’ appearance.

The approach employed in both patients involved injection of onabotulinumtoxinA into a wide variety of muscles on both sides of the face and neck. The total doses used (109–156 units per session) were substantially higher than in most previous facial palsy studies.^4-6 This was because we did not limit ourselves to treating synkinesis, hyperkinesis and facial asymmetry, but also applied the principles of full-face aesthetic treatment8 to obtain an anti-aging, rejuvenating effect.

The two patients were treated differently according to individual functional alterations of the facial muscles, but the overall approach remained within our standardized framework (Table 1). In both cases, we have reported here on the treatment and outcomes across the first 3 sessions. These were given at intervals of 3–6 months, in line with the typical duration of effect of BoNTA, although there is evidence from previous studies of prolonged effects beyond 6 months in facial palsy.¹ At each treatment session, patient photographs were captured in various projections both in static and dynamic pose. Results were verified at follow-up appointments 2–3 weeks after initial treatment. Touch-ups were given if necessary, typically to modulate the synkinesis that sometimes develops, particularly after treating the hyperactive (healthy) side of the face.

In both cases, patient photographs demonstrate the improvements achieved (Figures 1 and 2); GAIS assessments also suggested substantial aesthetic enhancements. Neither patient experienced any significant complications. This aligns with data from systematic reviews of previous studies of BoNTA in facial palsy, which have suggested low rates of major complications.^1,6 Furthermore, a recent randomized trial comparing three different BoNTA formulations in patients with synkinesis observed no major adverse events.⁴Many facial muscles were treated that would not normally be included in aesthetic BoNTA procedures for non-palsy patients – such as zygomaticus major, risorius, levator labii superioris, depressor labii inferioris, and endopalpebral orbicularis oculi. Thus, a deep knowledge of the functional anatomy of the facial muscles is required. Furthermore, injection depth is crucial; some muscles must be treated at their deep origin, some at their cutaneous insertion, and others may potentially be treated at either (based on individual patient needs).Following initial BoNTA treatment, each subsequent round of therapy should be adapted as required. Indeed, injection quantities in the two patients described here varied somewhat between sessions (Table 2). We noted that some asymmetries reduced in severity between sessions. For example, the chin area was always hyperactive and synkinetic, but showed a high degree of improvement even as the pharmacologic effect of BoNTA declined over time. We also attained sustained symmetrization of the eyebrows. Our findings align with previous data suggesting that BoNTA continues to be effective over multiple treatment sessions in patients with facial palsy.⁹

Both patients were extensively treated in the platysma to achieve a lifting and anti-aging effect within the lower third of the face. Normally, to obtain a lifting effect during non-palsy aesthetic treatment, we would reduce the action of the platysma, which has a depressive activity in its mandibular insertion, thereby fostering the antigravity effects of the muscles of the middle third of the face. In palsy cases, one side of the face has no active elevator muscles. Hence, it is even more important to reduce platysma activity, in order to rebalance asymmetric tissue descent.

CONCLUSIONS