INTRODUCTION
Facial palsy is a common problem from which many patients do not completely recover and hence have to live with chronic sequelae.1 These may include discomfort, functional deficiencies, and aesthetic defects that can have significant physical and mental consequences and a detrimental impact on quality of life.2,3
Botulinum neurotoxin type A (BoNTA) is a key tool in the management of facial palsy, reducing associated synkinesis and hyperkinesis while also improving facial balance and overall aesthetics.1,4-6 Improvements in quality of life have also been demonstrated.1,7 Furthermore, BoNTA injection is minimally invasive and repeatable, and usually associated with few major adverse events;1,4,6 hence, BoNTA may be used as part of a long-term management strategy.
Standardized protocols are currently lacking for the use of BoNTA in patients with facial palsy.3,7 Owing to the great variety of clinical presentations, every case should be assessed and treated on an individual basis. Nonetheless, it is important for practitioners to achieve some degree of systematization within their overall methodology.
We have developed a full-face and neck approach to the treatment of facial palsy with BoNTA using standardized entry points, dose ranges and injection depths (Table 1). The overall focus is on:
• Treatment of both sides of the face to ameliorate synkinesis of the affected side, minimize hyperkinesis of the unaffected side, and improve overall facial symmetry.
• Treatment not just of the face but also both sides of the neck, with the aim of obtaining a progressive rejuvenation that minimizes the negative aesthetic effects of facial palsy.
Here, we present case studies of two patients with facial hemiparesis treated with BoNTA (onabotulinumtoxinA, Allergan, Dublin, Ireland) using this approach. The standard dilution was used for all treatments (50 units of onabotulinumtoxinA in 1.25 mL of saline solution).
CASE 1
A 53-year-old woman presented with left-side Bell’s palsy that had developed late in pregnancy when she was 40 years old. Routine blood testing and analyses for neurotropic viruses were negative. She was treated with corticosteroids until delivery.
Since then, she has had left facial hemispasm with painful tonic–clonic contractures, particularly in the lower face. Previous attempts at drug therapy with clonazepam, pregabalin, baclofen and gabapentin yielded only temporary and partial improvements. The addition of complementary treatments, such as B vitamins, physiotherapy, acupuncture and magnet therapy, had no benefit. She was also treated with BoNTA injections 2–3 times per year, primarily in the upper third with little treatment of the mid- and lower face; the neck was not injected. This approach was largely unsuccessful.
At 47 years of age, she underwent left retromastoid microcraniectomy to solve a vascular–nervous conflict at the origin of the left facial nerve in the bulb-pontin. After surgery, resolution of hemispasm was noted in the upper third of the face, with slight persistence in the middle third, but no change in the lower third. She was subsequently treated only with BoNTA on an irregular basis. The patient self-assessed the results using the 5-point Global Aesthetic Improvement Scale (GAIS): 1 = worsened; 2 = no change; 3 = improved; 4 = much improved; 5 = very much improved. Using this scale, the change was rated as a 3, representing an ‘improved’ appearance.
The patient began treatment at our center in April 2019, based on a full-face and neck approach using onabotulinumtoxinA (Table 2; Figure 1A). Repeat treatment using a similar injection pattern was undertaken in June 2019 and October 2019. Excellent results were achieved, as shown and described in Figure 1. Results on GAIS were assessed by the patient as a 5, representing a ‘very much improved’ appearance.
FIGURE 1. Full-face and neck treatment with onabotulinumtoxinA in a patient with facial palsy. A 53-year-old woman with left-side Bell’s palsy. Her injection plan with onabotulinumtoxinA is provided in (part A). She is also shown before (parts B–G) and 1 month after the first session of treatment (parts H–M). Notable features of the result include: good symmetrization, which was particularly evident in the eyebrows; relaxation of the chin area (which had been in constant contraction before treatment) and disappearance of synkinesis on the affected side; harmonization of the smile, with a reduction of hyperkinesis on the healthy side; maintenance of the ability to close her eyes despite treatment of the intrapalpebral portion of the orbicular muscle on the affected side; reduced platsymal contraction, which promoted a new aesthetic balance of facial contours; and general rejuvenation of the whole face, including the mandibular line. In part A: procerus, orange; corrugator supercilii, red; frontalis, mid-blue; orbicularis oculi, yellow; nasalis, dark green; zygomaticus major, pink; risorius, purple; depressor labii inferioris, pale blue; platysma, pale green; mentalis, dark blue.
CASE 2
A 68-year-old woman presented with post-surgical facial palsy on the left side, which had developed after excision of an acoustic nerve neurinoma at 45 years of age. For several months after surgery, she had to keep the eyelid on the paralyzed side closed with a plaster.
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.
FIGURE 2. Full-face and neck treatment with onabotulinumtoxinA in a patient with facial palsy. A 68-year-old woman post-surgical facial palsy on the left side. Her injection plan with onabotulinumtoxinA is provided in (part A). She is also shown before (parts B–F) and 1 month after the first session of treatment (parts G–K). Notable features of the result include: good symmetrization of the entire face; relaxation of the chin area and the eyebrow of the affected side (which had been in constant contraction before treatment) with associated disappearance of chin synkinesis and reduced upper eyelid synkinesis on the affected side; harmonization of the smile, with a reduction of hyperkinesis on the healthy side; maintenance of the ability to close her eyes despite treatment of the intrapalpebral portion of the orbicular muscle on the healthy side; and general rejuvenation of the whole face, including the mandibular line, chin and lips. In part A: procerus, orange; corrugator supercilii, red; frontalis, mid-blue; orbicularis oculi, yellow; nasalis, dark green; zygomaticus major, pink; risorius, purple; levator labii superioris alaeque nasi, cream; depressor labii inferioris, pale blue; platysma, pale green; mentalis, dark blue.
DISCUSSION
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
Use of BoNTA across the whole face and neck is a minimally invasive approach to the aesthetic treatment of facial palsy with a low risk of major complications and the potential for excellent results. When treating these patients, it is essential to find a balance between the relaxing effects of BoNTA and preservation of residual motor function. If treatment is performed gradually by a skilled practitioner, an acceptable compromise between aesthetics and function can be achieved.
In the two cases described here, we have demonstrated marked improvements in synkinesis, hyperkinesis and facial symmetry, and also shown an anti-aging effect similar to that achieved with normal full-face treatments using BoNTA.8Results stabilized across multiple sessions of repeat treatment.
DISCLOSURES
ACKNOWLEDGMENT
REFERENCES
2. Cabin JA, Massry GG, Azizzadeh B. Botulinum toxin in the management of facial paralysis. Curr Opin Otolaryngol Head Neck Surg. 2015;23:272-280.
3. Serrera-Figallo MA, Ruiz-de-León-Hernández G, Torres-Lagares D, et al. Use of botulinum toxin in orofacial clinical practice. Toxins. 2020;12:112.
4. Thomas AJ, Larson MO, Braden S, Cannon RB, Ward PD. Effect of 3 commercially available botulinum toxin neuromodulators on facial synkinesis: A randomized clinical trial. JAMA Facial Plast Surg. 2018;20:141-147.
5. Shinn JR, Nwabueze NN, Du L, et al. Treatment patterns and outcomes in botulinum therapy for patients with facial synkinesis. JAMA Facial Plast Surg. 2019;21:244-251.
6. Lapidus JB, Lu JC, Santosa KB, et al. Too much or too little? A systematic review of postparetic synkinesis treatment. J Plast Reconstr Aesthet Surg. 2020;73:443-452.
7. Mehdizadeh OB, Diels J, White WM. Botulinum toxin in the treatment of facial paralysis. Facial Plast Surg Clin North Am. 2016;24:11-20.
8. D’Emilio R, Rosati G. Full-face treatment with onabotulinumtoxinA: Results from a single-center study. J Cosmet Dermatol. 2020;19:809-816.
9. Neville C, Venables V, Aslet M, Nduka C, Kannan R. An objective assessment of botulinum toxin type A injection in the treatment of postfacial palsy synkinesis and hyperkinesis using the Synkinesis Assessment Questionnaire. J Plast Reconstr Aesthet Surg. 2017;70:1624-1628.
SOURCE
Content and images republished with permission from the Journal of Drugs in Dermatology.
Adapted from original article for length and style.
The Journal of Drugs in Dermatology is available complimentary to US dermatologists, US dermatology residents, and US dermatology NP/PA. Create an account on JDDonline.com and access over 15 years of PubMed/MEDLINE archived content.
Did you enjoy this case report? You can find more here.
This webinar was previously recorded on July 1, 2020 and is now available on demand.
In Partnership with The Journal of Drugs in Dermatology
Business intellect, a vital aspect of managing a practice, is not taught in residency. From the infancy of their training, dermatologists are trained to think broadly and scrupulously, using each clue, each corporeal sense, and each available tool to accurately diagnose and manage a plethora of cutaneous conditions. After residency, dermatologists set out armed with the knowledge and drive to deliver expert care to their future patients. However, despite their education and best intentions, lack of business acumen can hinder even the brightest and most motivated of practitioners. In order to enlighten oneself in the complicated field of business management, clinicians are left to fend for themselves, often learning as they go, sometimes making unnecessary mistakes, and adjusting their business practices reactively. Retrospective “trial and error” learning is time-consuming, cumbersome, and costly. Why not short track and get the goods without the trial and error, making costly mistakes and taking years. The new book, The Business of Dermatology is a cornerstone achievement in the standardization of business education for dermatologists.
Edited by Drs. Jeffrey S. Dover and Kavita Mariwalla, and authored by impressive experts in the field, The Business of Dermatology offers a comprehensive guide to opening, maintaining, and sustaining a practice. To start, the power of this textbook fundamentally lies in the experience and scope of its authorship. The authors were hand-selected by the editors ensuring that each chapter was written by a tried and true expert in that subject. Unlike other textbooks in the field of business management and administration that are primarily written by individuals from the business world, some of whom have no insight into the inner machinations of the medical world, or hands-on experience, the authors of this book are well-known, respected dermatologists that hail from thriving practices of their own. The reader has an unprecedented opportunity to learn from the firsthand experiences of top authorities who live and breathe dermatology. Using conversational prose, the authors depict their experiences, trials, and errors, employing specific real-world examples and scenarios while tackling each subject.
A notable forte of The Business of Dermatology is the sheer breadth and range of topics discussed in the textbook by medical as well as surgical dermatologists. Opening and managing a practice is a daunting endeavor with twists, turns, and hidden hurdles that one cannot foresee until stumbling across them. The Business of Dermatology unveils those twists, turns, and hurdles for the reader, taking the “guessing game” out of the equation. Fifty-five chapters elucidate every aspect of running a practice, covering all practice-relevant topics, including office space and equipment, managing financials, diverse practice models, human resources, employment considerations, patient issues, pricing, essential surgical tools/supplies, marketing, and much more. The Business of Dermatology lays bare every facet of handling a dermatologic practice, so much so that even a well-run, seasoned practice stands to learn new tools and tips to elevate itself to a higher level.
And now more than ever in the “Time of Covid” we are in desperate need of information from The Business of Dermatology. Many of us are inventing the wheel with the significant changes that are occurring in Dermatology, and the practice of our specialty.
The wealth of knowledge endowed in each chapter is written and formatted in such a style that renders each chapter extremely easy to read and comprehend. First, the prose used in the chapters is conversational – as such, the reader is fully immersed in each topic as if he/she were having a face-to-face chat with the authors. Furthermore, references are used only when absolutely necessary. The reader is not bogged down by superfluous references and discussions that may dim the vital discussion points of the chapters. Finally, embedded within each chapter are practical tips that are immediately implementable and a Top Ten list that highlights the key take-home points, making “reading on the run” possible. The novice practice owner need not fear the residency dogma of “trying to drink from a gushing fire hydrant” with this easy-to-read, catchy and focused textbook.
ODAC Dermatology, Aesthetic & Surgical Conference’s Medical Director, Dr. Adam Friedman, discusses the ODAC 2021 program, reasons to attend and more!
To view the full agenda, click here: https://orlandoderm.org/agenda/
According to ODAC Vice-Chair Dr. Joel Cohen, Director of AboutSkin Dermatology (Greenwood Village and Lone Tree, Colorado), and Associate Clinical Professor at the University of California at Irvine, the pendulum is swinging back to heavy resurfacing in areas such as around the mouth and around the eyes that really need it. He uses full-field erbium resurfacing and shares why this is the way to go.
Next Steps in Derm, in partnership with ODAC Dermatology, Aesthetic and Surgical Conference interviewed Drs. Susan Weinkle and Jackie Yee to get their expert opinion on how to train the aesthetic eye. Watch as they share their views from a dermatologist and a plastic surgeon perspective.
Click here to view the on-demand recordings.
On April, 1, 2020, the Journal of Drugs in Dermatology (JDD) and SanovaWorks brands, including ODAC launched Part I of the webinar series: COVID-19: Urgent Dermatology and Aesthetic Issues for Dermatology.
Over the course of the 2 hours, Joel L. Cohen, MD and 6 different thought leaders joined the COVID-19 conversation, discussing the pressing questions that are on the minds of many dermatologists and providers in the country. The initial broadcast attracted 1,900 registrants and nearly 800 attendees comprised of physicians, residents, fellows, nurse practitioners and physician assistants. Attendees were interested and engaged throughout the entire 2 hours with a 76% average attentiveness and 72% average interest rating.
The on-demand broadcast has attracted over 500 registrants as of April 9th and is available on JDDonline.com.
On April 7, 2020, Part II of the webinar series was broadcasted: COVID-19: Your Questions Answered. Dermatology experts and thought leaders examined the legal and financial concerns of dermatology providers during the global coronavirus pandemic. Experts discussed furlough vs. layoffs; mortgage and rent relief programs; the CARES Act; the pros and cons of leveraging NPs or PAs for teledermatology and more. Then, hear questions answered by our panel of experts; discussed practical tips you can use in your practice right now; and how to move forward with patient care. Part II attracted 1,300 registrants with nearly 700 attendees. Attendees were engaged and interested throughout with an 82% attentiveness average and 75+% interest rating.
The on-demand broadcast of Part II will be available on April 11, 2020 on JDDonline.com.
During the 2020 ODAC Dermatology, Aesthetic and Surgical Conference, Dr. Amy McMichael, Professor and Chair of Dermatology at the Wake Forest University School of Medicine, sat down with Next Steps in Derm to share important updates regarding treatments on the horizon for the most common forms of hair loss. Dr. McMichael will be presenting at Skin of Color Update 2020 with lectures including Hair & Scalp Disorders in SOC: Diagnostic Approaches and Hot Topics & Controversies in Photoprotection: Making sense of it all.
Source: The Dermatologist
The following is an excerpt from The Dermatologist article on Q&A with ODAC Dermatology, Aesthetic and Surgical conference faculty, Terrence Keaney, MD.
More and more men are seeking cosmetic procedures to improve their appearance and slow the aging process. In addition to anatomical differences, men have different concerns about how they look compared with women. Terrence Keaney, MD, discussed these concerns and trends among male aesthetic patients, and also shared pearls for treating this patient population at ODAC Dermatology, Aesthetic and Surgical conference in Orlando, FL.
Dr Keaney is founder and director of SkinDC and an assistant clinical professor of dermatology at George Washington University School of Medicine.
The Dermatologist: What are some common trends among male aesthetic patients?
Dr Keaney: Like broader trends in aesthetics, there is no cookie cutter technique for treating men. Gender is just one data point, albeit a fairly important one because it affects biology, anatomy, behavioral expectations, etc. When evaluating a new cosmetic patient, gender, age, ethnicity, and other patient factors play a role in creating a customized treatment plan.
Understanding aesthetic procedures among male patients has not been well-studied and has not been on the top of many aesthetic providers minds, most likely because men occupy a smaller percentage of cosmetic patients. However, the number of men seeking minimally invasive procedures is growing.
As more men seek cosmetic treatment, it is important that physicians and practitioners know how to approach these patients from a treatment perspective, as well as how to discuss complications from these procedures because these scenarios may be different compared with female patients.
The Dermatologist: What are some of the differences between male and female patients that dermatologists should keep in mind?
Dr Keaney: The number one difference between men and women is anatomy. Anatomy really dictates how a provider will perform a procedure, especially fillers.
The facial anatomy of men is very different than women. For example, the distribution of fat is different between the sexes. Men have less subcutaneous fat in the face, especially in the medial cheeks and middle of the cheek, and do not have high cheekbones, which dictates where a filler would be placed. The apex of the cheek tends to be lower and more towards the middle in men, whereas the apex tends to be high and lateral in women and is considered a very feminine feature.
Behaviors, such as goals and expectations of cosmetic procedures, differ between men and women as well. Men care about different factors than women. Specifically, men worry about 3 areas: the hairline, eyeline, and jawline. When discussing aesthetic procedures and performing a full-face analysis of male patients, I often refer back to these 3 areas because I know men tend to worry about them the most.
However, this does not mean I do not use fillers on the cheeks or the mid-face. When I use a filler, I explain to the patient so they understand how this procedure may influence how their jaw looks or their eyes look. Otherwise, they may not be interested in that treatment option.
Other major concerns among men include hair loss and body contouring.
Source: Practical Dermatology
Susan Weinkle, MD, has been awarded the Outstanding Educator and Mentor in Dermatology Award by the ODAC Dermatology, Aesthetics & Surgical Conference, in partnership with the Journal of Drugs in Dermatology (JDD).
The award recognizes Dr. Weinkle for her long-standing commitment to educating and mentoring the next generation of dermatologists and for devoting a major portion of her professional life to enhancing the practice and profession of dermatology through education.
“Susan has given all of us in aesthetics so much of her time and energy, and I am honored to present this award to her.”“It is a pleasure and an honor to recognize the tireless work of exceptional leaders in dermatology,” said Shelley Tanner, CEO and president of SanovaWorks, which produces the JDD, ODAC, Derm In-Review, and Next Steps in Dermatology. “Not only do these dermatology leaders dedicate their entire lives to benefiting patients every day, but after the ‘work day’ ends, they spend countless hours involved in activities to improve the specialty’s future. We congratulate Dr. Weinkle for being chosen for this award.”