Premium
Two‐step highly selective neurectomy for refractory periocular synkinesis
Author(s) -
Hohman Marc H.,
Lee Linda N.,
Hadlock Tessa A.
Publication year - 2013
Publication title -
the laryngoscope
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.181
H-Index - 148
eISSN - 1531-4995
pISSN - 0023-852X
DOI - 10.1002/lary.23873
Subject(s) - synkinesis , neurectomy , refractory (planetary science) , medicine , materials science , composite material , alternative medicine , pathology , palsy
Botulinum toxin type A (BTA) has become a gold standard of treatment for facial synkinesis, and now is an integral part of the treatment paradigm for patients with this sequela. In our center, we routinely treat 30 patients per week with botulinum toxin. Addressing synkinesis via a multidisciplinary approach, we begin with physical therapy and later add chemodenervation to the regimen. Injections of BTA (onabotulinumtoxinA, Botox Cosmetic, Allergan Inc, Irvine, CA) are repeated every 3 to 6 months, if they offer symptom relief. Repeated BTA treatments can lead to decreased effectiveness through the well-described phenomenon of antibody development. Once BTA has lost its effectiveness, despite increased doses, we advance to type B botulinum toxin (BTB) (rimabotulinumtoxinB, Myobloc, Solstice Neurosciences LLC, Louisville, KY). We currently treat 390 patients with BTA injections; only 10 are receiving BTB. The same loss of effectiveness that occurs with BTA can occur with BTB; historically, these patients have continued their physical therapy but experience worsening of synkinesis symptoms in the absence of chemodenervation. To address this problem in the periocular area, we have refined the decades-old technique of selective neurectomy. Traditionally, the procedure did not identify specific nerve branches responsible for the synkinesis symptoms, resulting in either unsatisfactory relief, worsening of facial weakness, or a combination of both. Therefore, we resolved to avoid these problems through precise titration of the neurectomy. To this end, the procedure was divided into two steps: 1) Facial nerve dissection is done under general anesthesia; 2) The patient is awakened and recovered, and then the neurectomy is performed, achieving the exact degree of orbicularis oculi weakening required to decrease ocular synkinesis while avoiding lagophthalmos.