Acta Oto-Laryngologica

ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20

Individualized management of facial synkinesis

based on facial function

Cecilia Montalban Maria & Jin Kim

To cite this article: Cecilia Montalban Maria & Jin Kim (2017): Individualized
management of facial synkinesis based on facial function, Acta Oto-Laryngologica, DOI:
10.1080/00016489.2017.1316871

To link to this article: http://dx.doi.org/10.1080/00016489.2017.1316871

Published online: 04 May 2017.

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ACTA OTO-LARYNGOLOGICA, 2017
http://dx.doi.org/10.1080/00016489.2017.1316871

ARTICLE

Individualized management of facial synkinesis based on facial function

Cecilia Montalban Maria and Jin Kim
Department of Otorhinolaryngology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Korea

ABSTRACT ARTICLE HISTORY

Objectives: The researchers analyzed facial patterns in subjects with facial synkinesis after facial paraly- Received 29 January 2017
sis and evaluated the involved muscles to aid in the development of effective treatments for facial Revised 25 March 2017
synkinesis. Accepted 31 March 2017
Methods: A total of 142 subjects were included in the study, the primary measure for synkinesis was
determined by video analysis involving the strongest combination of two muscle groups that contrib- KEYWORDS
uted to facial expression. The secondary measure of synkinesis was the analysis of its severity using Facial nerve; facial paralysis;
the SB grading system, while observing the number of facial synkinetic movements. facial synkinesis; botulinum
Results: The most common type of facial synkinesis was oral–ocular synkinesis (n ¼ 137). Other synki- toxin A
nesis such as ocular–oral, ocular–nasal, ocular–chin, ocular–stapedial, chin–ocular and chin–oral synki-
nesis continued to coexist together with oral–ocular synkinesis. The results of BTX-A treatment are
assessed based on the number of facial synkinetic movements observed and the evaluation of initial
facial function.
Conclusion: The effectiveness of botulinum toxin A (BTX-A) treatment should be considered on an
individual basis, according to the initial state of facial function. A patient with mild facial synkinesis
restricted to the oral–ocular area and with a high score on the Sunnybrook (SB) facial nerve grading
system would be the best candidate for BTX-A treatment.

Introduction significant disability and social stigmatism. It is impossible

Facial muscles that have been degenerated or atrophied by
denervation of facial nerve, produces reinnervation of axons
with non-native muscle groups. This results in a phenom-
enon, called synkinesis. It is defined as the presence of unin-
tentional motion in one area of the face, produced during
intentional movement in another area of the face [1]. It is
one of the most troubling sequelae of facial nerve paralysis.
Several mechanisms have been proposed for synkinesis. This
includes aberrant regeneration [2] with third-degree nerve
injuries by Sunderland’s classification [3], ephaptic transmis-
sion in which neighboring axons at the site of injury stimu-
late each other [4], and hyper-excitability of the facial nucleus
in the cerebral motor cortex [5]. Such synkinetic movements,
regardless of the proposed mechanism, may develop during
neural repair process 3–6 months after injury. They become
particularly apparent during spontaneous facial movements,
especially during emotional expressions such as involuntary
blinking or smiling [6,7]. These findings indicate that nuclear
hyperexcitability may play an important role in the develop-
ment of synkinesis and in aberrant regeneration. Many
researchers have also reported that even the central cortex
can undergo reorganization secondary to peripheral facial
palsy [8–10]. The pathophysiology underlying synkinesis is
very complex and multifactorial.
Facial synkinesis or facial hyperkinesis, which is the most
common side effect of facial palsy, is associated with
to completely alleviate synkinetic movements. Long-lasting
treatments and analysis of objective systems for facial synki-
nesis are still under development.
Since the early 1990s, multiple studies have demonstrated
the experience of BTX-A and have shown to be quite effect-
ive in the treatment of facial synkinesis. It has now gained
acceptance as the appropriate management for patients with
facial synkinesis. In addition, patients receiving BTX-A ther-
apy have shown significant improvement in measures of
quality of life, social interaction and personal appearance
based on a subjective questionnaire.
Synkinesis is often named by combining two involved
muscles groups: the intended muscle group is named first,
followed by the unintended muscle group. For example,
oculo–oral synkinesis involves oral commissure movement
with voluntary eye closure. This combination of two muscle
groups lead to the most unpleasant and localized sequelae of
facial synkinesis. Identification of the intended muscles as
well as the associated unintended muscles accurately is
essential for providing major symptomatic relief to patients
with facial synkinesis.
Two major treatment options are used to alleviate facial
synkinesis. Facial neuromuscular retraining (FNMR) and
botulinum toxin A (BTX-A) injections.
Both treatment options have been developed in order to
reduce the activity of synkinetic muscles and to enhance the

CONTACT Jin Kim jinsound@gmail.com Department of Otorhinolaryngology, Inje University College of Medicine, Ilsan Paik Hospital, 2240 Daehwa-dong,
IlsanSeo-gu, Goyang-si, Gyeonggi-do, Korea
ß 2017 Acta Oto-Laryngologica AB (Ltd)
2 C. M. MARIA AND J. KIM
Figure 1. Various types of facial synkinesis exist (A) Oral–ocular synkinesis, (B) Ocular–oral synkinesis, (C) Chin–oral synkinesis, (D) Platysmal synkinesis, (E)
Ocular–chin synkinesis, (F) Ocular–nasal synkinesis, (G) Chin–ocular synkinesis.
activity of paralytic muscles, resulting to improve overall
facial motility. However, the simultaneous presence of both
paretic and synkinetic (hyperkinetic) muscles make the
treatment of facial synkinesis difficult. The weakening of
paretic muscles mitigate the beneficial effect of treatment of
facial synkinesis, instead of reducing synkinetic movements.
The researchers analyzed facial patterns in subjects with
facial synkinesis after facial paralysis and evaluated the
involved muscles. The results from this study could aid in
the development of effective treatments for facial synkinesis.
Materials and methods
A total of 142 subjects (58 male, 84 female) presenting with
post-facial paralysis synkinesis were seen and examined
from March 2012 to July 2015 and were included in the
study. Mean age of the subjects was 42.3 ± 4 years and mean
duration of facial paralysis was 37.6 ± 6.8 months.
The etiology of facial paralysis was as follows: Bell’s palsy
in 74 patients (52.1%), traumatic facial palsy in 29 patients
(20.4%), Ramsay-Hunt syndrome in 27 patients (19.0%), iat-
rogenic injury in eight patients (5.6%) and a mass on the
middle ear in four patients (2.8%).
The primary measure of synkinesis was determined by
video analysis of the strongest combination of two muscle
groups contributing to a facial expression. The involvement
of a third muscle with the initial two muscle groups made it
Table 1. The groups of facial muscles.
Muscle group Involved muscles
Oral muscles Orbicularis oris, zygmoaticus major and minor,
levator labiil superiroris, levator anguli oris,
depressor labii inferioris, depressor anguli oris
Ocular muscles Orbicularis oculi, corrugators, frontalis, procerus
Chin muscles Mentalis, depressor labii inferioris, depressor labii
superioris, sepressor angulioris
Platysmal muscles platysma
Nasal muscles dilator naris, compressor naris
Stapedial muscle stapedial
difficult to localize the involved muscles. In such a situation,
while the subject was making facial expressions, the two
muscle groups were selected based on the patient’s most
inconvenient symptom (feeling of muscular connection)
(Figure 1, Table 1). The existence of involved third muscle
excluded because most of patients felt too strong connection
of involved two muscles enough to disregard third muscle
involvement and considered to be minor problems.
The secondary measure of synkinesis was the analysis of
its severity by using the Sunnybrook (SB) facial nerve grading
system [11]. Facial function was directly evaluated by two
experienced physicians from the Department of
Otorhinolaryngology at the Inje University College of
Medicine at least one year after the onset of facial paralysis
(the mean follow-up period: 2.3 ± 0.8 years). In the measuring
of facial function using the SB score, the physicians
should measure resting symmetry, voluntary movement

Table 2A. Sunnybrook facial nerve grading system.
Table 2B. Babak and Kimberly (BK) classification for chronic facial palsy.
Classification Chronic facial palsy
Type A Normal facial function
Type B Partial paralysis with mild synkinesis
Type C Partial paralysis with moderate to severe synkinesis
Type D Partial paralysis without synkinesis
Type E Complete facial paralysis
and synkinesis. For the calculation of SB score, ‘voluntary
score 4-resting symmetry 5-synkineis ¼ total score’.
Actually, we could detect the big difference at every 10 scores
changes and the authors classified the SB facial nerve grading
system for every 10 scores to estimate the severity of facial
function.
The cases were then classified into five categories of
chronic facial paralysis using the Babak and Kimberly (BK)
classification [12]. Although they are mostly not as familiar
as House–Brackmann system, SB score system and BK clas-
sification were adopted to make detailed division of the
severity of facial synkinesis (Table 2(A,B)).
All subjects (combination of two muscles) were treated
with BTX-A (NabotaV; Daewoong, Seoul, Korea; 1.5 units/
R
0.1 ml). Total amount of BTX-A was 12.4 ± 3.6 unit for the
oral–ocular synkinesis around periocular muscles, 18.6 ± 3.8
unit for the ocular–oral synkinesis around periocular and
perioral area, 10.4 ± 3.2 unit for the chin–oral synkinesis,
15.6 ± 4.7 unit for chin–ocular synkinesis at involved muscles,
14.6 ± 5.4 unit for ocular–chin synkinesis, 12.4 ± 4.8 unit for
ocular–nasal, and 35.4 ± 6.8 unit for platysmal synkinesis.
ACTA OTO-LARYNGOLOGICA 3
FNMR was administered to enhance the paralytic muscu-
lature [13]. FNMR was conducted to develop for maintain-
ing the effect of botulinum toxin treatment for facial
sequelae. We used a combination strategy including admin-
istration of BTX-A followed by daily half-mirror biofeedback
rehabilitation for about one year from the first injection.
The classic mirror biofeedback exercise has a number of dis-
advantages. Exercise is disturbed by movement of the non-
paralyzed side, and patients may find it difficult to compare
paralyzed and non-paralyzed sides. To overcome the disad-
vantage of mirror exercise, a new mirror exercise method,
known as half-mirror biofeedback, was developed especially
after BTX-A injections.
All facial expressions such as involuntary eye closure
with volitional mouth movement, or involuntary contrac-
tion of cheek muscles with volitional eye closure, involving
two combined muscles or groups of muscles on the
affected side were dynamically examined. An ice pack was
applied on the injected area for vasoconstriction prior to
local anesthesia. BTX-A was injected using a tuberculin
syringe with a 27-gauge needle. The injection sites included
the following: at the center point of the two involved
muscle groups, the intended muscle group, and the associ-
ated unintended muscle group. For example, for the reduc-
tion of the oral–ocular synkinesis or ocular–oral synkinesis,
injection sites were designated at the periocular and perio-
ral areas including the zygomaticus major and minor
muscles, respectively.
4 C. M. MARIA AND J. KIM
The effects of combination therapy with localized BTX-A
injections in two-combined muscle groups followed by
FNMR was monitored according to the visible number of
facial synkinetic movements evaluating the change in SB
score from the initial SB grading score, one year after the
first BTX-A injection.
Results
The average SB facial nerve grading score was 62.4 ± 14.5.
Eight patients had a 80–90 score on SB system, 27 patients
had 70–80 score, 46 patients had 60–70 score, 20
patients had 50–60 score, 28 patients had 40–50 score and
12 patients had <40 score. Based on the BK classification,
76 patients had mild synkinesis, while 66 patients had mod-
erate or severe synkinesis. There were no patients for type
A, D or E (Figure 2).
The most common type of facial synkinesis, which was
observed in 58 patients, was oral–ocular synkinesis
(n ¼ 137). Other types of synkinesis observed were ocular–
nasal synkinesis (n ¼ 12), ocular–chin synkinesis (n ¼ 8),
ocular–stapedial synkinesis (n ¼ 4), chin–ocular synkinesis
(n ¼ 7), chin–oral synkinesis (n ¼ 29) and platysmal synkine-
sis (n ¼ 13). Among them, 26 subjects had one kind of syn-
kinesis, 47 subjects had two kinds of synkinesis, 45 subjects
had three kinds of synkinesis, and 24 subjects had more
than four kinds of synkinesis (Figure 3).
The amount of BTX-A injected per site varied from 1.5
to 3 U. The total dose used per patient was 17.4 ± 13.9 U.
The end-result of combination therapy of localized BTX-A
injections on two-combined muscle groups, followed by
FNMR, was evaluated using the change in SB score from the
Figure 2. (A) The etiology of facial palsy. (B) The number of patients classified by initial SB score. (C) The type of facial palsy by BK classification.
initial SB grading score, 1 year after the first BTX-A
injection.
Average facial change after BTX-A and FNMR treatment
by SB score was 12.5 ± 7.3 in patients, who had a facial func-
tion of 80–90 by initial SB score, 17.2 ± 10.4 in patients with
70–80 SB score, 18.5 ± 9.8 in patients with 60–70 SB score,
8.6 ± 6.2 in patients with 50–60 SB score, 7.8 ± 4.4 in patients
with 40–50 SB score and 5.2 ± 4.2 in patients with less than
40 SB score. Average facial change of facial synkinesis after
BTX-A and FNMR treatment was 23.6 ± 15.2 in subjects
who only had one kind of synkinesis, 17.7 ± 8.6 in subjects
with two kinds of synkinesis, 5.2 ± 3.8 in subjects with three
kinds of synkinesis, and 4.5 ± 4.2 in patients with more than
four kinds of synkinesis. Statistical significances were found
in patients, who had a facial function of 70–80 by initial SB
score and in patients with 60–70 SB score (by independent
sample t-test, p < .05). Also average facial change of facial
synkinesis after BTX-A and FNMR treatment was 23.6 ± 15.2
in subjects who only had one kind of synkinesis, 17.7 ± 8.6
in subjects with two kinds of synkinesis with statistical dif-
ferences (by independent sample t-test, p < .05) (Figure 4).
We have observed that instead of experiencing an elimin-
ation of facial synkinetic connections, eight subjects with
multiple synkinesis (>3 kinds of facial synkinesis) felt an
aggravation of facial paralysis or numbness after BTX-A
injection.
Discussion
Although BTX-A is the most suitable material for control of
hyperkinesis. The main problem of most patients is an
abnormal synchronization of facial movements, occurring

with voluntary and reflex activity of muscles that normally
do not contract together [14].
This abnormal synchronization is derived from the simul-
taneous presence of both paretic and synkinetic (hyperkin-
etic) muscles after facial nerve injury. The severity of
abnormal synchronization correlates with the degree of
sequelae of facial paralysis, which is graded according to the
SB grading score or the BK classification. Individual differ-
ences of abnormal synchronization make it very difficult to
treat the subject’s synkinetic movements. Since BTX-A can
only eliminate the hyperkinesis and cannot control the syn-
chronization of facial movements, the beneficial effect of
treatment of facial synkinesis is reduced or nullified by mak-
ing paretic muscles weaker instead of reducing synkinetic
movement.
In this study, the results of BTX-A and FNMR treatment
are dependent on the initial states of facial movement.
About 42% of the subjects had severe sequelae of facial palsy
(< 60 on SB score). Most of them had a slight enhancement
of facial function on an average. This finding could be
thought to elicit more weakness on paretic muscles together
with reduction of hyperkinetic movement. More
Figure 3. (A) The clinical analysis of facial synkinesis. (B) The visible number of synkinesis.
Figure 4. (A) Average facial change after BTX-A and FNMR treatment by SB. (B) Average facial change after BTX-A and FNMR treatment by visible number of facial
synkinesis.
ACTA OTO-LARYNGOLOGICA 5
interestingly the results of our show that the effectiveness of
the BTX-A treatment also depends on the visible number of
facial synkinesis. BTX-A and FNMR treatment is not guar-
anteed to be effective in subjects with more than three kinds
of facial synkinesis. We have frequently observed that
instead of experiencing an elimination of facial synkinetic
connections, subjects with multiple synkinesis, such as those
found in severe chronic facial palsy, feel an aggravation of
facial paralysis or numbness after BTX-A injection.
These findings are limitations of BTX-A and FNMR
treatment for synkinesis. In addition, due to collateral
innervation after several months, the beneficial effects are
not long lasting. It is widely known that synkinesis after
facial nerve injury can occur in any region of the face, and
in most patients, surgical treatment is neither necessary nor
desired. Every case should be considered individually
because there is great variation in clinical presentation, as
was exemplified in this study. Oral–ocular synkinesis
observed in 58 subjects was the most common type of facial
synkinesis (n ¼ 137) in this study. Followed by ocular–nasal
synkinesis (n ¼ 12), ocular–chin synkinesis (n ¼ 8), ocular–
stapedial synkinesis (n ¼ 4), chin–ocular synkinesis (n ¼ 7),
6 C. M. MARIA AND J. KIM
chin–oral synkinesis (n ¼ 29) and platysmal synkinesis
(n ¼ 13). Almost all synkinesis, except oral-ocular synkinesis,
continued to exist in combination with other synkinesis.
In conclusion, the effectiveness of BTX-A and FNMR
treatment should be individualized according to the initial
state of facial function. An individualized abnormal syn-
chronization generated by facial sequelae after facial paraly-
sis, makes it very difficult to treat patient’s synkinetic
movement. In case of severe chronic facial palsy with mul-
tiple synkinesis, BTX-A injection could cause more weakness
of paretic muscles instead of reduction of synkinetic move-
ment. Patients with only mild synkinesis in the oral–ocular
area with a high score on SB facial nerve grading system,
would be the best candidate for BTX-A and FNMR treat-
ment for facial synkinesis.
Conclusions
Synkinesis after facial nerve injury can occur in any region
of the face. The most common type of facial synkinesis
seen in this study was oral-ocular synkinesis. Ocular–oral
synkinesis was also frequently observed. Ocular–oral,
ocular–nasal, ocular–chin, ocular–stapedial, chin–ocular and
chin–oral synkinesis always coexisted with oral–ocular syn-
kinesis. The results of BTX-A and FNMR treatment are
assessed based on the number of facial synkinetic move-
ments observed, and the evaluation of initial facial function
using the SB facial nerve grading system. BTX-A and
FNMR treatment should be considered on an individual
basis, according to the initial state of facial function.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of this article.
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