Orbicularis Oculi Research Articles

Orbicularis Oculi Myectomy as an Adjunctive Procedure to Modified Selective Neurectomy for Postparalysis Facial Synkinesis: Technical and Safety Considerations.

Orbicularis Oculi Myectomy as an Adjunctive Procedure to Modified Selective Neurectomy for Postparalysis Facial Synkinesis: Technical and Safety Considerations.

Efficacy and Safety of Hyaluronic Acid Combined with Botulinum Toxin Type A in the Treatment of Midcheek Groove: A Prospective Study.

The midcheek groove, a diagonal wrinkle in the infraorbital and infrazygomatic regions, disrupts the entire midface smooth lines and impacts facial aesthetics. Despite current treatments' limited effectiveness, including hyaluronic acid fillers and surgical risks, and the neglect of the medial orbicularis oculi muscle, this study explores the efficacy and safety of combining botulinum toxin type A with sodium hyaluronate injection for midcheek groove treatment, considering anatomical and clinical factors. In this prospective study, healthy participants with midcheek grooves (depth >3 mm) were treated with botulinum toxin type A combined with hyaluronic acid injections. Data were collected at baseline, 4, 12, and 32 weeks as well as 30 min after treatment, and at 1, 3, and 6 months follow-up. Changes in the depth of the midcheek groove were measured using a three-dimensional scanner and assessed using the Patient Satisfaction Assessment Scale. Subgroup analyses were performed to assess the impact of different clinical subtypes on treatment outcomes. Thirty-six volunteers completed this study, and the midcheek groove depth was significantly reduced at 30 min after treatment and at 1, 3, and 6 months of follow-up (p < 0.001). The medial half of the midcheek groove had the best efficacy at 1 month after treatment, while the lateral half responded best at 30 min after treatment. Subgroup analyses showed that clinical subtypes affected treatment efficacy. No complications or severe adverse reactions were observed. Botulinum toxin type A combined with hyaluronic acid injection effectively improved the midcheek groove. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of Chemodenervation on Ocular Synkinesis.

Background: Chemodenervation is widely used for management of synkinesis in patients with facial palsy, but there is limited objective data assessing treatment effect. Objective: To measure the eyelid palpebral fissure height at rest and during movement after chemodenervation of the orbicularis oculi muscle among patients with ocular synkinesis, as measured on photographs with computerized facial analysis application. Methods: A retrospective review of patients who underwent initial chemodenervation to the orbicularis oculi for synkinesis was conducted from January 1, 2015, and July 26, 2023. Changes in palpebral height following injection "at rest" and during "pucker" (activation of ocular synkinesis) were calculated using the Emotrics+ program. Results: Nineteen patients were identified: 78.9% female, 73.7% White, and a mean age of 49.74 ± 13.62yrs. They received a mean of 11.45 ± 3.57 units to the orbicularis oculi. A mean 37.63 ± 11.21 days elapsed between injection and postinjection photograph. Palpebral fissure height increased by a mean of 1.16 ± 1.86 mm while "at rest" (p = 0.014) and 2.31 ± 1.35 mm during "pucker" (p < 0.01). Injected dose was not associated with changes in palpebral fissure height "at rest" (p = 0.141) or during "pucker" (p = 0.125). Conclusions: Our findings suggest that chemodenervation of the orbicularis oculi improves palpebral fissure height in ocular synkinesis, more so during dynamic motion.

“Floating Island Flap”—A New Technique for the Reconstruction of Full-Thickness Lower Eyelid Defects with Spontaneous Healing (Folded V-Y Island Flap with Orbicularis Oculi Muscle)

Background: Due to the high incidence of malignant tumors of the lower eyelids and the widespread use of surgery for their treatment, the reconstruction of tissues in this area is a frequent task for surgeons. Methods for restoring full-thickness lower eyelid defects are often invasive, pose a significant risk of complications, and do not provide optimal results. Methods: The authors developed a simple technique for the reconstruction of full-wall defects of the lower eyelids. It is a V-Y-type musculocutaneous island flap from the lower eyelid, with the orbicularis oculi muscle folded in the upper part and partially left for spontaneous healing, called by the authors a “floating island flap”. Between 2012 and 2023, 39 patients were operated on using this method. Results: Surgical procedures performed under local anesthesia were well tolerated by the patients. The healing process was quick and well accepted. Complications were rare. The most common were: eye irritation and temporary swelling of the flap. In 37 patients, proper protection of the eyeball and good esthetic results were achieved; only in two cases was the cosmetic result assessed as poor. Corneal defects occurred in two cases and healed after conservative treatment. In no cases was reoperation necessary. Conclusions: The developed method is simple and effective. It can be widely used in the reconstruction of full-thickness defects of the lower eyelids.

Surgical correction of medial canthal widening associated with aging: two case reports

Medial canthal widening due to aging is a frequent concern among elderly individuals, often resulting in cosmetic dissatisfaction. This condition commonly involves caruncle exposure and elongation of the medial canthus, sometimes requiring surgical intervention. While medial epicanthoplasty is commonly used to address medial canthal deformities, age-related changes call for a modified approach to optimize aesthetic results. We present two cases of elderly patients whose medial canthal widening was corrected using a modified V-Y advancement flap combined with medial canthal tendon tightening. This technique involves elevating a V-flap and suturing the pretarsal orbicularis oculi muscle and medial canthal tendon to restore medial canthal contour. In one case, an 85-year-old man with unilateral caruncle exposure experienced marked cosmetic improvement post-surgery. In the second case, a 71-year-old woman with bilateral medial canthal widening also reported significant improvement. Both patients had no complications and expressed satisfaction with their postoperative appearance. This surgical approach effectively reduced caruncle exposure and enhanced eye shape with no recurrence or wound healing problems. Medial canthal widening from aging can be successfully treated with a V-Y advancement flap and medial canthal tendon tightening, offering elderly patients a dependable solution with favorable cosmetic results.

Deciphering the Refined Musculature of the Brow Area in Asians by Micro-Computed Tomography.

The brow area is an important aesthetic unit. Accurate anatomical understanding of the brow is important for clinical treatments related to this region. Due to the complexity of the brow area and limitations of methods, there are still some controversies regarding its musculature description. This article aims to reveal the detailed musculature using micro-computed tomography (micro-CT) combined with histological staining. Eight fresh cadaver (16 hemifaces) were obtained. Eight hemifaces were processed with phospho-tungstic acid contrast staining for micro-CT scanning and reconstruction. The other corresponding 8 hemifaces were prepared with Masson staining. The orbicularis oculi muscle (OOM), frontalis muscle (FM), depressor supercilii (DS) and procerus muscle (PM) were situated superficially. The FM terminated and connected with its antagonistic muscles at 2-5 mm above the brow but the fusion line descended in lateral third. The corrugator supercilii muscle (CSM) originated from the periosteum, extending laterally and superficially. During its course, it mainly penetrated the FM. CSM had broad subcutaneous insertion, covering about 77.9% ± 7.5% of the hairy brow. CSM fibers connected to the subcutaneous fiber septa to directly transmit contraction force. The soft tissue on the lateral side of the brow was looser than that on the medial side. Our study deepens the understanding of the precise anatomy of the brow area and helps guide clinical practice.

"Folding Fan Flap": A Novel and Dependable Surgical Technique for Crow's Feet Correction by Z-Plasty of Orbicularis Oculi Muscle.

The challenge of crow's feet surgical correction is to minimize the complication caused by orbicularis oculi muscle (OOM) resection while ensuring the operative effect. This study aims to propose a novel technique to solve this problem and evaluate its efficacy. From January 2022 to April 2024, all patients who received "Folding fan flap" in our institution were included. The outer third of the OOM below the lateral canthus was dissected and received Z-plasty to exchange width for length and reconstruct the muscle dynamics in a non-circular direction. Preoperative and postoperative smiling crow's feet were assessed by two independent physicians using the Lemperle wrinkle scale. At least six months after surgery, patient satisfaction with wrinkle correction, naturalness of facial expression, and local flattening was subjectively evaluated on a five-point scale. Complications including hematomas, incomplete eyelid closure, facial stiffness, and forehead numbness were recorded. A total of 32 patients (63 sides) were included with a mean follow-up of 13.9 ± 5.2 months. Postoperative assessments showed a significant reduction in Lemperle's score from 4.8 ± 0.4 to 1.5 ± 0.5 (P=0.000). Regarding the satisfaction of surgical outcomes and the naturalness of facial expressions, thirty patients (93.8%) were very satisfied. There were no severe complications such as hematomas and incomplete eyelid closure. Preliminary clinical studies demonstrated the efficacy of this technique in ensuring outcomes while preserving normal dynamic expressions. By Z-plasty of the outer circle of OOM, the muscle dynamic was successfully modified rather than eradicated. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Thermostable bFGF Improves Cell Lifespan by Enhancing Cell Activity in the Long-Term Culture of Human Orbicularis Oculi Stem Cells.

Stem cells derived from human orbicularis oculi muscle (hOOM) are a valuable resource for cell therapy. However, when stem cells are continuously cultured, their abilities tend to deteriorate over time. One method to address this issue is to use basic fibroblast growth factor (bFGF) to maintain the stem cell functionality. The limitation is that bFGF is unstable under mammalian cell culture conditions with a half-life of only 8 hours, which poses a significant challenge to the production and maintenance of high-quality stem cells. In this study, we used thermostable bFGF (TS-bFGF) and demonstrated that hOOM-derived stem cells cultured with TS-bFGF exhibited superior proliferation, stem cell function, reduced reactive oxygen species, and cellular senescence delay effect compared to cells cultured with wild-type bFGF. Considering the pivotal role of stem cells in broad ranges of applications such as regenerative medicine and cultured meat, we anticipate that TS-bFGF, owing to its thermostability and long-lasting properties, will contribute significantly to the acquisition of high-quality stem cells.

Combination of Pretarsal and Preseptal Botulinum Toxin Injections in the Treatment of Blepharospasm: A Prospective Nonrandomized Clinical Trial

PurposeTo compare the efficacy of two botulinum toxin (BoNT) injection methods, pretarsal (PT) combined with preseptal (PS) injection (PT-PS) and conventional PT injection, in the treatment of benign essential blepharospasm (BEB). DesignProspective nonrandomized clinical trial. MethodsFrom January 2023 to April 2024, 95 BoNT injections into orbicularis oculi were performed in 45 BEB patients, including 52 PT-PS injections s and 43 PT injections. Jankovic Rating Scale (JRS) and Blepharospasm Disability Index (BSDI) were used to assess motor symptoms. The efficacy of two injection methods for BEB was compared in terms of latency to response (LTR), latency to the peak response (LPR), duration of peak response (DPR), duration of response (DOR), satisfaction degree, and possible complications. ResultsBoth injection methods significantly improved JRS and BSDI scores in patients with BEB. However, PT-PS injections showed a shorter LTR [(4.00(3.00,6.00) vs 5.00(4.00,7.00) days, p=0.024] and LPR [23.50(16.00,26.00) vs 26.00(20.00,30.00) days, p=0.040], a longer DPR [88.00(80.50,104.75) vs 75.00(65.00,92.00) days, p=0.003] and DOR [135.00(118.50,153.75) vs 121.00(107.00,135.00) days, p=0.003] than PT injections. Patients with PT-PS injections were more satisfied than those with PT injections [9.50(8.50,10.00) vs 8.00(7.50,9.00), p<0.001], and around 2/3 of patients were more willing to receive the combined injection method later. Among patients receiving PT-PS injections, only one case experienced ptosis, and there were no significant differences in other complications such as lacrimation, dry eyes, and blurred vision between the two injection methods. ConclusionsPT-PS injections of BoNT showed more advantages in the treatment of BEB than PT injections in terms of both their efficacy and patients’ satisfactions.

Correction of Infraorbital Dark Circles Using Autologous Adipose-Derived Collagen Filler: A Novel Regenerative Option.

Numerous intrinsic and extrinsic factors, notably the aging process, contribute to the development of infraorbital dark circles. These features, commonly associated with old age and fatigue, are caused by a disruption of dermal melanin and impairment of skin barrier function. Common aesthetic concerns affecting patients with infraorbital dark circles are primarily owing to lean and translucent lower eyelid skin overlying the orbicularis oculi muscle. This study aimed to present a novel technique for correcting infraorbital dark circles utilizing an adipose-derived extracellular matrix concentrate-adipose collagen fragment (ACF)-to correct infraorbital dark circles. Female patients (n = 94) aged 20-38 who presented infraorbital dark circles were enrolled to assess the efficacy of this technique for an eight-month follow-up. Following intradermal injections with ACF filler, the clinical outcome was determined by responses to GAIS and patient satisfaction surveys. Statistical analysis was performed with the one-way ANOVA test, and a p value of < 0.05 was considered statistically significant. Patients (n = 92) completed a single treatment session and underwent an eight-month follow-up. Eighty patients (86%) reported being "highly satisfied" or "satisfied" with the outcome and responded that the technique resulted in brighter, tighter, and smoother infraorbital skin. Over 97% of patients were rated as "improved," "much improved" and "Very much improved" throughout the follow-up on GAIS by three independent surgeons (p < 0.05). The statistical analyses demonstrated the percentage differences among groups are highly significant (p < 0.0001). No irregularity or lump was observed during the follow-up. Two patients were excluded from the study due to having undergone cosmetic eyelid surgery. Intradermal ACF filler represents a novel approach to addressing infraorbital dark circles and yields significantly high patient satisfaction. ACF fillers provide a degree of bio-stimulation, and adipose-derived concentrate is a natural filler with regenerative effects used in periorbital rejuvenation. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Relationship Between Glabellar Contraction Patterns and Glabellar Muscle Anatomy: A Magnetic Resonance Imaging-based Study.

Glabellar contraction patterns were introduced to the scientific literature to help guide glabellar neuromodulator injection algorithms. However, the relationship between the underlying musculature and its influence on these glabellar contraction patterns is unclear. The aim of this study was to identify via Magnetic Resonance Imaging (MRI) glabellar muscle parameters that display an influence on the distribution of individual glabellar contraction patterns. Thirty-four healthy young individuals of Caucasian Polish descent were investigated (17 women, 17 men) with a mean age of 23.6 years and a mean BMI of 22.8 kg/m2. MRI-based measurements of length, thickness, width and surface area of procerus, corrugator supercilii, orbicularis oculi and frontalis muscles were conducted. Unadjusted models revealed that there was no statistically significant difference between the five glabellar contraction types and the investigated muscle parameters indicating that independent of the skin rhytid pattern, the underlying musculature was not different between the investigated groups in this sample with all p ≥ 0.102. Adjusted models revealed that sex was the most influential factor due to males displayed in general higher values for the investigated parameters when compared to females. The results of this study reveal that based on the MRI parameters investigated and based on the investigated cohort, there does not appear to be a strong relationship between glabellar contraction patterns and underlying glabella muscle anatomy. Utilizing glabellar contraction patterns to design neuromodulator treatment algorithms may be of variable clinical merit.

Full-Incision Double-Eyelid Blepharoplasty with Selective Sensory Nerve Preservation.

Full-incision double-eyelid blepharoplasty can result in upper eyelid skin numbness postoperatively. However, few studies have examined sensory loss after eyelid surgery. We propose a novel surgical approach with selective sensory nerve preservation to prevent postoperative upper eyelid numbness. We enrolled 90 patients who underwent full-incision double-eyelid blepharoplasty with selective sensory nerve preservation from March 2021 to February 2022. Major longitudinal nerves that spread vertically to the palpebral margin under the orbicularis oculi muscle in the medial portion of the upper eyelid were dissected and carefully preserved. Eyelid sensation was measured using a Cochet-Bonnet filament-type esthesiometer at four predetermined anatomical locations in the upper eyelid. The mean esthesiometry reading was calculated at the preoperative and 2-week and final postoperative visits. The follow-up duration was 2-4 months (mean, 3 months). The mean esthesiometry readings at the inferonasal location were 5.22 cm (n=170, SD=0.28) preoperatively, 5.21 cm (n=170, SD=0.31) at 2 weeks postoperatively, and 5.22 cm (n=170, SD=0.29) at the final postoperative visits. Sensation was not significantly different between the second visit and the baseline (P=0.014) or between the final visit and the baseline (P=0.158). None of the patients reported a reduction in their subjective eyelid sensation. Full-incision double-eyelid blepharoplasty with selective sensory nerve preservation can prevent postoperative upper eyelid numbness while producing reliable and dynamic palpebral creases. The vital nerve branches of the upper eyelid can be preserved, thereby retaining skin sensation near the margin of the eyelid. We propose a novel full-incision double-eyelid blepharoplasty technique that incorporates selective sensory nerve preservation to prevent postoperative upper eyelid numbness. Full-incision double-eyelid blepharoplasty with selective sensory nerve preservation can prevent postoperative upper eyelid numbness while producing reliable and dynamic palpebral creases. The vital nerve branches of the upper eyelid can be preserved, thereby retaining skin sensation near the margin of the eyelid. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The small incisions combined with interrupted buried suture blepharoplasty: flexible-rigid fixation.

The traditional full incision blepharoplasty is the most commonly used in Asia. However, it has significant drawbacks like long recovery period, excessive surgical marks etc. We offer a new suture idea and combine it with interrupted suture buried blepharoplasty to improve these disadvantages. In our procedure, the orbital septum is opened and separating the levator aponeurosis-the retro-orbital septum complex under this 3-5 millimeters small incision, a flexible-rigid fixation would be made: suture fixation was made to the tarsus-the complex-lower lip orbicularis oculi muscle. We interrupted bury the sutures in the uncut skin between the two small incisions. This paper included 333 patients divided into small incision groups using flexible-rigid fixation (n = 244, 73.3%) and full incision groups using rigid fixation (n = 89, 26.7%). Both at 6-month and at 5-year postoperative follow-up, the satisfaction of small incision group was statistically higher than the full incision group. The overall postoperative complication rate was statistically significantly less in the small incision. The permanence was not statistically different. For Assignment of Postoperative Effort Score (PES) results, at 6 months postoperatively, the mean score was 8.29 ± 1.32 in the small incision group, 7.86 ± 1.54 in the full incision group. At 5 years postoperatively, the mean score was 7.48 ± 1.45 in the small incision group, 7.51 ± 1.73 in the full incision group. None were statistically different. The small incisions group achieves a higher level of patient satisfaction and more mild trauma in the surgical area, has a low complication rate, and a decent degree of durability.

Clinical Efficacy of Bionic Blepharoplasty Using the Flexible Suspension and Semiflexible Suspension Double-Insurance Methods.

To investigate the clinical effect of the double insurance method of flexible suspension and semiflexible suspension in bionic blepharoplasty. Between January 2020 and January 2022, a total of 115 patients (230 eyes) underwent double eyelid plastic surgery with flexible suspension and semiflexible suspension. Herein, we present a new type of double eyelid surgery that preserves the orbicular muscle of the anterior tarsus without removing the tissue. First, the loose fatty fascia layer between the anterior tarsus and the orbicularis oculi muscle was completely removed to a distance of 2mm from the base of the eyelashes, leaving the compact pretarsal levator aponeurosis. Then, the anterior tarsus orbicularis oculi muscle and the upper levator aponeurosis were sutured and fixed (flexible suspension). Finally, the skin and the upper levator aponeurosis were sutured in the flexible suspension space (semiflexible suspension). Six months after surgery, the patient's double eyelid shape had recovered well, and the satisfaction rate reached 97.3%. Among the unsatisfied patients, 1 patient had a single-focused shallow eyelid line which was associated with postoperative hematoma, and 2 patients felt that the double eyelid line was narrow. All 3 patients achieved satisfactory results after reoperation. The bionic double eyelid method with flexible suspension and semiflexible suspension can restore the natural double eyelid anatomy very well by reconstructing the connection between the orbicularis oculi muscle or skin and the upper palpebral levator aponeurosis. After the operation, the incisions healed quickly and smoothly. The eyelid depression and fleshy feeling were not obvious when the eyes were closed. Consequently, the patient's satisfaction was very high.

Motor unit number index in Bell's palsy: A potential electrophysiological biomarker for early evaluation.

Reliable, noninvasive early diagnostics of neuromuscular function in Bell's palsy, which causes facial paralysis and reduced quality of life, remain to be established. Here, we aimed to evaluate the utility of the motor unit number index (MUNIX) for the quantitative electrophysiological assessment of early-stage Bell's palsy, its correlation with clinical assessments, changes following treatment, and association with clinical prognosis. MUNIX measures were recorded from the bilateral zygomaticus, orbicularis oculi, and orbicularis oris muscles of 10 healthy individuals and 64 patients with Bell's palsy. The patients were assessed by two specialist neurologists using the House-Brackmann and Sunnybrook Facial Grading Systems. Repeat assessments were performed on 20 patients with Bell's palsy who received treatment. Additionally, the 64 patients were reassessed using clinical scales after a 1-month interval. The MUNIX values of the main affected muscles on the affected side were lower than those on the healthy side in patients with Bell's palsy (p<.05). The MUNIX measurements significantly correlated with the clinical facial nerve palsy scale scores (p<.05). Significant improvements were observed in the MUNIX values on repeat testing following treatment (p<.05). The baseline motor unit size index (the compound muscle action potential amplitude divided by MUNIX) was positively associated with improved clinical presentation after 1 month (p<.05). MUNIX can be used as an electrophysiological biomarker for the quantitative assessment of facial nerve palsy and treatment response, and as a prognostic biomarker, in patients with early Bell's palsy, and is recommended as a complement to conventional neurophysiological examinations.

Changes in oral health status and function among older adults through professional oral care and rehabilitation exercises

Objectives: To develop a program that combines the oral health promotion program for the elderly and to investigate the effect of improving oral function by applying the oral health promotion program to elderly people using welfare facilities. Methods: From June to October 2022, a total of 29 elderly individuals utilizing welfare facilities in the Gyeongnam region were recruited. The control group underwent surveys and objective oral health assessments. The experimental group participated in an oral health promotion program, consisting of oral functional rehabilitation exercises and expert oral health management, conducted once a week for 8 weeks at the facilities. Objective oral health assessments were conducted before, during (at 4 weeks), and after (at 8 weeks) the intervention period for both groups. Results: As a result of the oral health promotion program, it was confirmed that there was an improvement effect in bad breath (p&lt;0.001), saliva secretion amount (p&lt;0.001), orbicularis oculi muscle (p&lt;0.001), and plaque index (p&lt;0.001). Conclusions: A revitalization plan is needed so that the efficient oral health promotion program for the elderly can be reflected as a systematic and professional community care oral health management program.

Ultrasound-based histological differences in thickness between puffy eyelids and normal eyelids in Asian monolid women

BackgroundUpper eyelid tissue swelling is a common characteristic among Asian monolid individuals and is associated with a high incidence of complications following eyelid surgery. Currently, there is no precise definition for upper eyelid tissue swelling, necessitating further research to elucidate the specific causes contributing to upper eyelid puffiness. MethodBetween June 2023 and February 2024, we recruited 84 Asian monolid women categorized into groups based on the severity of upper eyelid tissue swelling: the puffy eyelid group and the normal eyelid group. High-frequency ultrasound was employed to capture images of the upper eyelids and measure the thickness of various tissue layers. This study aims to conduct a comparative analysis to identify the factors contributing to upper eyelid fullness, focusing on elucidating the underlying causes of this condition. ResultAll volunteers underwent bilateral upper eyelid ultrasound imaging. Significant differences were observed in the thickness of subcutaneous fat, pre-tarsal fat, retro-orbicularis oculi fat（ROOF）, and composite fat(ROOF and pre-aponeurotic fat) layer between the puffy eyelid group and the normal eyelid group. However, no significant differences were found in skin thickness or orbicularis oculi muscle thickness. Additionally, no significant differences were observed in the thickness of various layers of the upper eyelid tissue between the left and right eyes in all participants. ConclusionThickening of the upper eyelid fat layer is a primary cause of upper eyelid puffiness. In upper blepharoplasty, targeted removal of pre-aponeurotic fat, ROOF, and pre-tarsal fat can achieve precise reduction to correct upper eyelid puffiness effectively.

Botulinum toxin treatment for hemifacial spasm: harmonising neurological and aesthetic outcomes.

Hemifacial spasm (HFS) represents a challenging cranial movement disorder primarily affecting the facial nerve innervated muscles, with significant prevalence among Asians. Botulinum toxin type A (BoNT/A) injections, established as a primary therapeutic intervention since FDA approval, offer considerable effectiveness in alleviating spasms, albeit accompanied by challenges such as temporary effects and potential adverse events including facial asymmetry. This comprehensive review underscores the crucial need for harmonising neurological benefits and aesthetic outcomes in HFS management. The discussion delves into the interplay between facial aesthetics and neurological objectives in BoNT/A injections, emphasising precise techniques, dosages, and site considerations. Distinct aspects in neurological and aesthetic domains are also examined, including detailing the targeted muscles and injection methodologies for optimal therapeutic and aesthetic results. Importantly, evidence regarding various BoNT/A formulations, recommendations, and reconstitution guidelines in both neurology and aesthetics contexts are provided, along with a schematic approach outlining the stepwise process for BoNT/A injection in HFS treatment, addressing critical areas such as orbicularis oculi muscle sites, eyebrow correction strategies, mid- and lower-face considerations, contralateral injection sites, and post-injection follow-up and complication management. By highlighting the culmination of neurological efficacy and facial esthetics in BoNT/A treatment for HFS patients, this review proposes a holistic paradigm to achieve balanced symptomatic relief and natural aesthetic expression, ultimately enhancing quality of life for individuals grappling with HFS.

Neurosurgical Importance on Temporal Branch of the Facial Nerve.

We aimed to determine anatomic features of the temporal branch (TB) of the facial nerve and its relation to various anatomic landmarks on the face in order to prevent damage in the surgical approach after head trauma or in planned neurosurgical interventions. Nine male cadavers preserved with formalin, were bilaterally dissected under a microscope at the laboratory of anatomy department of the university. The anatomical features of the branch and branching pattern of facial nerve and its relationships with adjacent neurovascular structures were evaluated using descriptive statistical data. The mean distance at the lateral canthus level between the far most anterior branch and far most posterior branch of the TB (APD) was 14.93 mm. The mean distance to the tragus of the entrance point of the TB to the orbicularis oculi muscle (ETT) was 74.72 mm. The mean distance between the origin point of the TB to the tragus (TT) was 24.50 mm. The angle between the far most anterior branch and far most posterior branch at the level of the lateral canthus (APA) was minimum 15°, maximum 40° and the mean value of APA was 24.61°. The number of branches originating from the TB (NB) were one to three branches which lay under the zygomatic arch and two to five branches upper the zygomatic arch, respectively. The number of anastomosis between the TB and zygomatic branch (AN) varies between 1 and 4; AN was found to be less intense in 10 sides and very intense in eight sides. The APA and APD value is mentioned for the first time in this study and nerve angle is considered to be as important as temporal branching in directing facial neurosurgical operations. We found that the unsafety zone may be exist for a 40 degree and 1.5 cm long area at the lateral canthus level, especially on the zygomatic arc where branching pattern is greater and 2.5 cm in front of the tragus. The data is significant for neurosurgeons to reach exactly this area without causing postoperative complications such as facial paralysis.

Clinical and electrophysiological prognostic factors in predicting poor outcomes in patients with idiopathic facial nerve paralysis

ObjectiveThis study was designed to verify whether one or more clinical and neurophysiological parameters could predict a poor prognosis in idiopathic facial paralysis. MethodsSeventy-three outpatients with unilateral idiopathic facial nerve paralysis who visited our hospital within 7 days of onset. All patients received treatment according to a standard therapy protocol and ocular care. Patients’ baseline characteristics were assessed before initiating treatment, including demographic characteristics, facial nerve function assessment and previous medical history. House-Brackmann (H-B) grading system was performed at baseline and six months after the onset. Electroneurography (ENoG) and blink reflex tests were conducted 7–10 days after the onset of paralysis. Sunnybrook Facial Grading System (SFGS) was conducted at baseline, days 7–10 post-onset when the electrophysiological tests were performed, and one month after the onset. ResultsAccording to the H-B grade at 6 months following the onset, 58 patients (79.5 %) had a good prognosis, while 15 patients (20.5 %) had a poor prognosis. The CMAP amplitudes in three facial muscles (frontalis, orbicularis oculi, and orbicularis oris) were decreased, and ENoG values were increased in the poor prognosis group compared with the good prognosis group (all p < 0.01). The results of the blink reflex study showed that the group with a poor prognosis had a longer R1 latency compared to the group with a good prognosis. Additionally, the group with a poor prognosis exhibited a higher rate of R1 absence on the affected side (both p < 0.01). The findings of conditional logistic regression indicated that the absence of R1 on the affected side, frontalis ENoG, orbicularis oculi ENoG, and orbicularis oris ENoG were predictive factors of a poor prognosis for facial nerve palsy. The receiver operating characteristic (ROC) curves showed that the SFGS at 1 month after onset of 55 is considered a critical cutoff value for poor prognosis, with a sensitivity of 86.7 % and specificity of 91.4 %. ConclusionElectroneurography (ENoG) and blink reflex tests acquired within 7–10 days after the onset of paralysis are significant and highly valuable for predicting the prognosis of idiopathic facial nerve paralysis. Higher ENoG values of the muscles innervated by the facial nerve and the absence of R1 on the affected side of the blink reflex are predictive factors for a poor prognosis. The SFGS is a clinical tool that plays an important role in evaluating the prognosis of idiopathic facial paralysis, particularly one month after onset.