Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 1058e1063

Botulinum toxin injection of both sides of

the face to treat post-paralytic facial
synkinesis
Ki Hoon Choi, Seung Hwan Rho, Jun Myung Lee, Ju Hyun Jeon,
Si Young Park, Jin Kim*

Department of Otorhinolaryngology, Inje University College of Medicine, Ilsan Paik Hospital,

2240 Daehwa-dong, IlsanSeo-gu, Goyang-si, Gyeonggi-do, Republic of Korea

Received 4 October 2012; accepted 6 April 2013

KEYWORDS Summary Objective: An attempt has been made to produce a new ‘balance’ in facial dy-
Facial paralysis; namics between a paralysed and a non-paralysed face with reduction of synkinesis, by concom-
Botox itant injection of botulinum toxin A (BTX-A) on both sides in patients with long-lasting facial
sequelae.
Study design: Prospective clinical study.
Setting: University hospital.
Subjects and methods: Forty-two consecutive patients who recovered partially from facial
nerve paralysis were enrolled for this study. The amount injected per site of the paralysed side
with synkinesis varied from 1.5 to 2.5 U, and the total dose used per patient was 10e26 U
(mean 17.12
5.3 U). That of the non-paralysed side with muscular hypertrophy varied from
2.5 to 5 U, and the total dose used per patient was 35e72 U (mean 52.6
9.7 U). All patients
had been evaluated by the Sunnybrook (SB) facial nerve grading systems and developed dy-
namic facial asymmetry ratio.
Results: After administration of injection of BTX-A on both sides of the face, relief of facial
synkinesis and enhancement of facial symmetry were observed in all patients. Before the in-
jection, the patients showed an SB score of 38.8
10.68. After the injection, changes of syn-
kinesis and symmetry score were 7.9
1.81 and 8.4
3.25, respectively, resulting in a
58.4
12.46 score at the last evaluation. Before the administration, the mean
standard de-
viation (SD) value of dynamic facial asymmetry was 0.83
0.06 and it was increased signifi-
cantly to 0.90
0.05 1 month after administration.

* Corresponding author. Tel.: þ82 31 910 7114; fax: þ82 31 910 7518.
E-mail address: jinsound@gmail.com (J. Kim).

1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.04.012
Botox therapy of facial synkinesis
Conclusion: After BTX-A injection on both sides for synkinesis and contralateral hypertrophy, the
patients showed significant suppression of the synkinesis and improvement of facial symmetry
with resulting elevated quality of life, social interaction, personal appearance and food intake.
ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.
Facial nerve paralysis causes serious functional and psy-
chological disorders because it alters static and dynamic
facial symmetry and often produces an involuntary, un-
wanted effect, such as synkinesis between the orbicularis
oculi and the orbicularis oris muscle, or increase in
lacrimation of the affected eye.1e3 During the initial phase
of complete paralysis, complications are due to weakness
of the affected muscles, but when recovery is partial, facial
asymmetry and inability to refine fine movements can be
caused either by prolonged paralysis or by the development
of post-paralytic synkinesis.4
However, such patients with facial sequelae frequently
have their anaesthetics compromised by asymmetry, even
after modern successful procedures such as botulinum toxin
injection or microsurgical muscle transplantation have
been performed. The non-paralysed side, which acts
chronically against the weak antagonism of the contralat-
eral muscles, usually presents with facial muscular hyper-
trophy, wrinkles, furrows and deviation of the mouth.
Facial changes associated with facial sequelae can be
attributed to ‘unbalanced’ muscular activity, ‘unbalanced’
muscular hypertrophy and ‘unbalanced’ pattern of facial
expression. The appearance of facial expression can be
worsened as time goes on. So, for some patients, progres-
sive facial asymmetry, more than synkinesis, can lead to
low self-esteem and poor quality of life with age.5,6
Since botulinum toxin type A (BTX-A) was suggested for
the treatment of synkinesis after it was used successfully to
treat blepharospasm in 1985, it has been widely used to
treat such an unwanted, involuntary movement of the
affected side induced by unhealthy aberrant neural
regeneration.7,8
At the physiologic level, BTX-A produces chemical
denervation of muscle through the inhibition of acetyl-
choline release from somatic and autonomic nerve termi-
nals. When using BTX-A in high dose, a balance can be
achieved for treating ‘voluntary’ hypertrophic, non-
paralysed muscles while maintaining facial expression and
minimising ptosis.
In our institute, an attempt has been made to recover
facial symmetry by concomitant double injection of BTX-A
in patients with long-lasting facial sequelae, and the goal of
this study, in addition to reduction of synkinesis, is to
produce a new ‘balance’ in facial dynamics between the
paralysed and the non-paralysed face.
Material and method
Subjects
After the degree of facial synkinesis was evaluated by a
synkinesis score in the Sunnybrook (SB) facial grading
1059
system and the degree of facial asymmetry was evaluated
by a developed ratio of dynamic facial asymmetry
(described below), we decided to include the patients as a
study group who scored over 5 in the synkinesis score and
below 0.9 in the developed facial symmetry score.
Forty-two patients (22 females, 20 males, ranging from 8
to 78 years, mean: 48.3
20.3 years old), observed in a 2-
year time frame, who recovered partially from facial nerve
paralysis (24 patients with Bell’s palsy, 8 with herpes zoster
oticus, 7 with traumatic facial palsy and 3 with facial nerve
transection with reconstruction) were enrolled into this
study. All of them were affected by obvious synkinesis on
the affected side and contralateral muscular hypertrophy
due to compensative facial movement on the normal side
after several months or years of facial palsy. This study was
approved by the Committee for Medical Ethics of Inje Uni-
versity Hospital, and written informed consent was ob-
tained from all patients prior to the study.
BTX-A injection
All facial expression muscles or groups of muscles on both
sides were dynamically examined. An ice pack was applied
for vasoconstriction and local anaesthesia was given prior
to injection. BTX-A (Botox, Allergan Incorporated, Irvine,
CA, USA) was injected using a tuberculin syringe with a 27-
gauge needle. The amount injected per site of the para-
lysed side with synkinesis varied from 1.5 to 2.5 U, and the
total dose used per patient was 10e26 U (mean 17.12
5.3
U; Figure 1). That of the non-paralysed side with muscular
hypertrophy varied from 2.5 to 5 U, and the total dose used
per patient was 35e72 U (mean 52.6
9.7 U; Figure 1).
The mean time from onset of facial palsy was 16.9
months. Injection of botulinum toxin was planned to be
concomitant injection of both sides in a day, or several
days-term injection after first injection of one side.
Repeated injections of botulinum toxin were planned when
the patients feel a lot of discomfort by facial synkinesis and
contralateral hypertrophic movement or have an over 5
score in the synkinesis score and a below 0.9 score in the
developed facial symmetry score after the first injection.
Evaluation of synkinesis and symmetry
All patients had severe facial palsy with evidence of
denervation potentials on electromyography (EMG) and
evaluated by the SB facial nerve grading systems and
developed dynamic facial asymmetry ratio.
Facial photographs of pre- and post-injection were taken
with Canon Mark-II and degree of facial synkinesis and
facial asymmetry using a new developed facial scale after
botulinum toxin injection were evaluated (Figure 2).
1060 K.H. Choi et al.

Figure 1 The injection point of Botulinum toxin for ipsilat-

eral facial synkinesis (In this picture, the demonstration of
injected points were shown on the left side) and contralateral
facial muscular hypertrophy(the injected points were shown on
the right side). There were great variations on injected points
for contralateral facial hypertrophy because every cases were
considered individually according to their compensative
muscular development.

The degree of oraleocular synkinesis was evaluated by

asymmetry of the interpalpebral space width at the centre
point between the medial and the lateral canthus during
three designated mouth movements in the frontal view.
The degree of facial asymmetry was evaluated by com-
parison of the width of the superior palpebral eyelid, width
between the nasal tip and the horizontal lateral facial
endline, width between the mouth corner and the inferior
ear lobe and width of the lip at the point of centre of the
nostril. The patients were instructed to look at the lens of
camera and to concentrate on three designated eye
movements (eyelid closure with minimal effort, eyelid Figure 2 The degree of facial asymmetry (Dynamic facial
closure with maximal effort and look at over, three mouth asymmetry) was evaluated by width comparison of the superior
movements (say ‘e’, ‘o’ and a blowing balloon) and gross palpebral eyelid, width between nasal tip and horizontal
facial picture at rest (Table 1). The degree of facial lateral facial endline, width between mouth corner and infe-
asymmetry in a normal face was also evaluated for control rior ear lobe and width of lip at the point of center of nostril.
value after taking photographs of 100 volunteers. The patients were instructed to look at the lens of camera and
A questionnaire that contains 20 items related to the to concentrate on 3 designated eye movements(eyelid closure
psychological, social role aspects and the physical function with minimal effort, eyelid closure with maximal effort and
was designed to provide information about their most look at over), 3 mouth movements(say “e”, “o”, and blowing
remarkable changes in their ordinary life. balloon), and gross facial picture at rest.
Botox therapy of facial synkinesis 1061

Table 1 Example of the average of ratio by dynamic facial expression (Mean ratio Z Sum of calculated ratio/35,
0 < calculated ratio<1(complete symmetry).
Calculated ratio Resting Eyelid closure with Eyelid closure Look at Say Say Blowing
minimal effort with maximal the above “e” “o” balloon
effort
Width of the superior
palpebral eyelid(a/b)
Width of palpebral
fissure(a/b)
Width of lip at the
point of center of nostril(a/b)
Width between mouth
corner and inferior ear lobe(a/b)
Width between nasal tip
and horizontal lateral
facial endline(a/b)
Average Mean ratio

Results the delicate and complex function of the mimetic muscles.

After administration of a double injection of botulinum
toxin for synkinesis and contralateral hypertrophy, relief of
facial synkinesis and enhancement of facial symmetry were
observed in all patients (Figure 3). Changes in the SB score
are shown in Table 2. Before the injection, the patients
showed an SB score of 38.8
10.68. After the injection,
changes of synkinesis and symmetry score were 7.9
1.81
and 8.4
3.25, respectively, resulting in a score of
58.4
12.46 at the last evaluation. There was no differ-
ence in change of the symmetric score and the synkinesis
score between the aetiology of the facial palsy.
Before the administration of botulinum toxin, the
mean
standard deviation (SD) value of dynamic facial
asymmetry was 0.83
0.06 and it was increased signifi-
cantly to 0.90
0.05 1 month after administration.
Compared to the value of dynamic facial asymmetry
(0.95
0.03) of the normal face, there was a limitation
that could not be overcome by double injection. Botulinum
decreased the compensative contralateral hypertrophy
leading to a more symmetrical function of the cheek, per-
ioral and periocular regions (Figure 4).
Repeated injections were needed in 17 patients (40%) of
the total number due to redeveloped facial synkinesis and
contralateral hypertrophy. Two-time injections were
needed in the case of 10 patients and three-time injections
for seven patients for 28.4
6.3-month follow-up periods.
The average interval of injections was 10.6
3.7 months.
Adverse effects were observed in seven patients (16%)
on the ipsilateral paralysed side, lasted from 3 to 42 days
and included ptosis (four patients), pseudo Bell’s palsy (two
patients) and diplopia (one patient). Three patients com-
plained of difficulty in adapting themselves to the weak-
ened smile and two patients had little impairment of
speech.
Rehabilitation of the paralysed face is still a challenge and
every effort should be made, in confronting facial paralysis,
to preserve facial function.
Botulinum toxin has dramatically improved the man-
agement of patients with facial-movement disorders. It is
now a first-line agent for treatment of facial synkinesis.
Synkinesis after facial nerve injury can occur in any region
of the face, and botulinum toxin can be used to denervate
specific muscle groups.
Even after a successful procedure for synkinesis, patients
with facial paralysis frequently have their anaesthetics
compromised by asymmetry. The asymmetry is visible when
the face is at rest and in motion. Although the facial asym-
metry is initially due to the weak paralysed side that has
shallow nasolabial folds, depression of the angle of the
mouth, drooping eyebrow, absence of forehead lines and
flaccidity, the compensative non-paralysed side, which acts
chronically against the weak antagonism of the contralateral
muscles, presents with wrinkles, furrows, deviation of the
nose and the mouth to its side as time goes on.
However, it was already reported that the injection of
botulinum toxin in the non-paralysed side of the face had

Discussion Figure 3 Paragraphy of dynamic facial asymmetry showing

changes after double botox injection and normal control.
In spite of the development in instrumentation and tech- (There were significant differences on score of dynamic facial
niques, there is no method to totally satisfactorily replace asymmetry between before and after injection group).
1062 K.H. Choi et al.

Table 2 Changes of total SB score including symmetry and synkinesis score after administration of double injection of bot-
ulinum toxin for synkinesis and contralateral hypertrophy.
Etiology Injection time from Initial Last Change of resting Change of synkinesis
onset of facial SB SB symmetry score score by SB grading
palsy (months) by SB grading system
system
Bell’s palsy (n Z 24) 16.6
7.14 42.4
10.54 60
8.96 8
3.16 8
1.91
Herpes zoster oticus (n Z 8) 18.3
10.43 27.4
12.66 44
14.46 8.7
3.53 7.3
1.06
Traumatic facial palsy (n Z 7) 9.4
4.23 27.7
12.14 40.9
10.86 7.8
2.67 7.8
1.46
Facial nerve resonstruction after 16.4
12.86 18.3
4.93 25.4
5.94 11.6
2.88 7
1
transection (n Z 3)
Total average 15.2
6.48 38.8
10.68 58.4
12.46 8.4
3.25 7.9
1.81

Figure 4 A 58-year-old man with facial sequelae after temporal bone fracture on left side 2 years ago. (A) Before botox injection,
he had severe oral-ocular synkinesis and decreased muscular movement on left side. Marked nasolabial fold and bitterness furrow
were also developed by atrophic perioral muscles. The non-paralyzed side, which acts chronically against the weak antagonism of
the contralateral muscles, presents with facial muscular hypertrophy, wrinkles, furrows, deviation of the mouth. Facial changes
associated with facial sequelae can be attributed to "unbalanced" muscular activity, "unbalanced" muscular hypertrophy and
"unbalanced" pattern of facial expression. (B) Botulinum decreased the compensative contralateral hypertrophy leading to more
symmetrical function of the cheek, perioral, and periocular regions by partial weakening of the contralateral levator labii supe-
rioris zygomaticus and risorius muscles. Forehead asymmetry and elevated eyebrow by redundant forehead rhytides on contra-
lateral side was also decreased by partial weakening of forehead muscles. Oral-ocular synkinesis was reduced by botox injection on
periocular area. Overall botulinum toxin injection to both face decreased static and dynamic functional asymmetry.

improved the symmetry of the face at rest and in
motion.9e12 Further, we had frequently found that the
facial strength of the paralysed side had increased after
contralateral botulinum toxin injection, as an article re-
ported.13 This was due to improved motion of the paralysed
side, which was a secondary effect of the reduction of force
on the normal side, or it might be considered that the
central cortex undergoes reorganisation after botulinum
toxin injection as found on hemifacial spasm14,15 and we
named this phenomenon the ‘strength redistribution
phenomenon’.
In this study, after administration of a double injection
of botulinum toxin for synkinesis and contralateral hyper-
trophy, relief of facial synkinesis and enhancement of facial
symmetry were observed in all patients. Although it is
impossible to establish the exact point for botulinum toxin
injection due to individual variation in facial muscle anat-
omy and strength, botulinum decreased the compensative
contralateral hypertrophy, leading to more symmetrical
function of the cheek, perioral and periocular regions.
Even though there was a limitation that could not be
overcome, the mean
SD value of dynamic facial asym-
metry after injection was increased significantly to
0.90
0.05 1 month after administration, compared to the
value of dynamic facial asymmetry (0.83
0.06) before
injection.
It has been frequently observed that botulinum toxin
application of contralateral non-paralysed muscles with
ipsilateral paralysed muscles had resulted in long-lasting
decline of oraleocular synkinesis, unlike the rapid and
Botox therapy of facial synkinesis
temporary therapeutic effects of ipsilateral injection only,
and also observed that control of fine isolate facial move-
ment and strength of paralysed muscles have been gradu-
ally enhanced by reduction of strength on the normal side.
Further studies are needed to establish the ‘strength
redistribution phenomenon’ induced by contralateral
muscular botulinum toxin injection as mentioned above.
Further, we experienced that most patients experiencing
facial sequelae felt a lot of discomfort by too much
developed and too much powered contralateral facial
muscles, and after botox injection of the contralateral
side, most patients felt better and announced soft facial
movement of contralateral side preferentially, with respect
to paralytic facial movement. Botox injection on the
contralateral side has never induced any disfigured facial
paralysis on that side but induced natural facial movement
with weakening over-developed facial muscles. All the pa-
tients who had understood this phenomenon agreed on
botox injections of both sides before treatment.
The high frequency (9%) of ptosis was thought to be
induced by an overdose of botox injection compared to
small muscular volume of the superior palpebral muscle. It
is recommended to use a lower dose of botox on the su-
perior palpebral muscle over other areas to prevent ptosis.
In conclusion, the effect of botulinum toxin injection on
both sides of the face for synkinesis and contralateral hy-
pertrophy at the same time was examined in long-standing
facial paralysis patients by evaluating the SB facial nerve
grading score and dynamic facial asymmetry ratio using
facial photographs. After botulinum toxin injection on both
sides, the patients showed significant suppression of the
facial synkinesis and improvement of facial symmetry with
resulting elevated quality of life, social interaction, per-
sonal appearance and food intake.
Conflict of interest
None.
Funding
This work was supported by a grant of 2012 research
foundation of Inje University.
1063
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