Long-Term Enhancement of Botulinum Toxin Injections by Upper-Eyelid Surgery in 14 Patients with Facial Dyskinesias

ORIGINAL ARTICLE Long-term Enhancement of Botulinum Toxin Injections by Upper-Eyelid Surgery in 14 Patients With Facial Dyskinesias

Joseph A. Mauriello, Jr, MD; Rohit Keswani; Mark Franklin

Objectives: To determine the effects of upper-eyelid sur- or without upper-lid blepharoplasty (n = 5), upper-lid gery (limited myectomy, blepharoplasty, and levator apo- blepharoplasty alone (n = 6), or levator advancement with neurotic advancement) on patients who demonstrated a sub- or without blepharoplasty (n = 3). Mean subjective im- optimal response or residual heaviness of the upper eyelids provement was 68.75% after limited myectomy com- after botulinum toxin eyelid injections for facial dyskinesia. bined with blepharoplasty and 58.33% after levator and/or blepharoplasty surgery. Average duration of effect of Design: Retrospective study. injections increased from 122.1 days in the patients prior to undergoing eyelid surgery to 210.5 days after Subjects: Charts of 358 patients with a diagnosis of be- surgery. nign essential blepharospasm, Meige syndrome (with eyelid involvement), and hemifacial spasm were reviewed. Conclusions: Upper-eyelid surgery, including limited myectomy, enhanced the effect of the botulinum toxin Methods: Data were retrospectively analyzed and in- in this small group of patients. Patients with a subopti- cluded subjective and objective responses about botuli- mal response to injections in terms or moderate to marked num toxin injections (number and duration of effect of dermatochalasis with subjective heaviness of the eye- injections before and after eyelid surgery). lids, upper-eyelid blepharoplasty, and/or limited myectomy should be considered. Results: Of 358 patients with facial dyskinesias, 14 (3.91%) underwent upper-eyelid limited myectomy with Arch Otolaryngol Head Neck Surg. 1999;125:627-631

OTULINUM TOXIN injections the need for additional eyelid and facial are the treatment of choice surgery.2 Full myectomy may result in a for essential blepharo- cosmetic eyelid deformity.1 spasm, Meige syndrome The effects of upper-eyelid surgery, (eyelid, facial, and laryngeal- including limited myectomy, blepharo- cervicalB dystonia), and hemifacial spasm.1-21 plasty, and levator aponeurotic blepha- Patients who fail to respond ad- roptosis repair, on botulinum toxin treat- equately to botulinum toxin injections may ment for facial dyskinesias have not been opt for systemic pharmacological5,6 or sur- studied with long-term follow-up. gical treatment.1-4 Surgical alternatives in- During the past 14 years, 239 patients clude “full” myectomy or eyelid protrac- with blepharospasm and Meige syndrome tor excision (extirpation of the palpebral and 119 patients with hemifacial spasm were and orbital orbicularis muscle and proce- evaluated and/or treated with botulinum rus and corrugator supracilii muscles com- toxin. A retrospective study of a subset of bined with browplasty), limited myec- patients undergoing upper-eyelid surgery tomy (orbicularis muscle extirpation was performed on patients who received without brow surgery), or selective sev- botulinum toxin injections and who dem- enth-nerve ablation.20 Full myectomy and onstrated suboptimal response. Long-term seventh-nerve ablation may obviate the follow-up data were obtained. need for repeat botulinum toxin injections, while limited myectomy tends to enhance the effects of botulinum toxin From the Department of This article is also available on our Ophthalmology, University of injections, but repeat injections are nec- 1,3 Web site: www.ama-assn.org/oto. Medicine and Dentistry, New essary. Selective seventh-nerve abla- Jersey Medical School, Newark. tion often results in recurrence along with

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 MATERIALS AND METHODS Colorado needle (Colorado Biomedical, Evergreen), Bo- vie needle tip, Ellman needle, or carbon dioxide laser. Pre- tarsal skin-muscle flap was dissected from the inferior wound PATIENTS to expose the anterior tarsal surface to within 1 to 2 mm of the eyelid margin. Care was taken not to damage the hair follicles at the eyelid margin. Charts of all patients with a diagnosis of benign essential After hemostasis was achieved with cautery, gentle digi- blepharospasm, Meige syndrome, and hemifacial spasm were tal pressure on the globe prolapsed the underlying preapo- reviewed from the Oculoplastics Clinic of the Department neurotic fat in the nasal quadrant of the upper lid. A 3-mm of Ophthalmology of the University of Medicine and Den- horizontal incision was made through the orbital septum, tistry, New Jersey Medical School, Newark, and from a pri- where the preaponeurotic fat pad was identified 6 to 8 mm vate practice clinic (J.A.M.) from October 1983 through above the upper tarsal border. Care was taken not to in- August 1997. jure the underlying fused orbital septum and levator apo- The following data were obtained from patient rec- neurosis. ords: (1) duration of eyelid spasms prior to eyelid surgery, A cotton-tip applicator was introduced into the space (2) types of eyelid surgery, (3) overall subjective improve- occupied by preaponeurotic fat between the orbital sep- ment, and (4) number, dosage, and duration of effect of tum anteriorly and the levator aponeurosis posteriorly across botulinum toxin injections prior to and after eyelid sur- the entire eyelid. With the cotton-tip applicator in place, a gery. Only those patients who had surgery and were fol- monopolar cautery device (handheld battery-powered cau- lowed up by the primary surgeon (J.A.M.) were included tery or Bovie needle tip) was used to incise the orbital sep- in the study. tum across the horizontal width of the upper eyelid. Patients who experienced pain on botulinum toxin Superior to the fused levator aponeurosis and orbital injections before or after eyelid surgery were offered ice septum, the underlying levator was bluntly dissected from compresses and/or topical skin anesthesia with a mixture the overlying orbital septum and preaponeurotic fat pad. of local anesthetic cream (2.5% lidocaine and 2.5% prilo- The preaponeurotic fat, along with any retro-orbicularis caine) prior to injection. oculi fat, was debulked and excised with a unipolar cau- Patients who did not respond to botulinum toxin in- tery or vaporized with a bipolar cautery. A 2- to 3-mm hori- jections and who opted for full myectomy were excluded zontal band of preseptal orbicularis muscle (adherent to from the study. Patients introduced into the study prior to fused orbital septum and levator aponeurosis just above the the advent of limited myectomy underwent repair of blepha- superior tarsal border) was excised (Figures 1-3). This roptosis due to aponeurotic dehiscences and upper-eyelid excision facilitated surgical advancement of the levator apo- blepharoplasty for excessive dermatochalasis, creating heavi- neurosis. The pretarsal orbicularis muscle was bluntly dis- ness of the eyelid tissues. sected from the overlying skin across the entire eyelid over After surgery, all patients were asked (1) to estimate the tarsal plate. Care was taken not to buttonhole the skin. the percentage of improvement in eyelid spasms, (2) whether In patients undergoing levator advancement, the levator apo- they experienced enhanced eyelid symmetry and cosme- neurosis was identified, advanced, and secured to the up- sis, and (3) whether they would opt for surgery again. The per one third of the anterior tarsal surface with three 6-0 surgeon made an independent assessment of the cosmetic silk double-armed sutures. The horizontal mattress su- result. tures were placed at the medial, middle, and lateral as- pects of the upper tarsus. The arms of each suture were then SURGICAL TECHNIQUE brought through the edge of the levator. The eyelid posi- (BLEPHAROPLASTY WITH LIMITED MYECTOMY tion and contour were adjusted with the patient sitting up.19 OR LEVATOR ADVANCEMENT) In patients in whom levator advancement was not performed, the levator aponeurosis was plicated in its origi- Patients were prepared and draped with their entire face nal position with the 6-0 silk sutures. exposed. Approximately 3 mL of 0.5% bipuvacaine and 2% The preseptal portion of the palpebral orbicularis lidocaine with epinephrine was locally infiltrated into the oculi muscle and the orbital portion of the orbicularis upper eyelids, with oxygen delivered through the mouth muscle were dissected superiorly from any residual by the anesthesiologist, who administered monitored attachment to the orbital septum and superior orbital rim. sedation. In patients undergoing levator advancement only, These muscles were dissected from overlying skin superi- epinephrine was not used in the anesthetic injection mix- orly to the eyebrow and excised with sharp dissection ture to avoid stimulation of the Mu¨ ller muscle. Eyelid- (Figure 3). The skin wound was closed with interrupted crease incisions were marked with a marking pen to cre- 6-0 silk sutures or 6-0 polypropylene sutures. In each ate symmetry. An appropriate amount of excess skin was case, the lid crease was defined by the number of deep marked above the lid crease in patients undergoing con- bites taken through the underlying levator aponeurosis at comitant blepharoplasty. If excess skin was noted in the the time of skin closure. lateral canthal area, the incision was extended beyond the All patients were discharged from the outpatient sur- canthus. The incision through skin and muscle was made gery unit on the day of surgery. Ice compresses were ap- with a No. 15 blade, Ellman needle (Ellman International plied to the eyelid tissues every hour for 15 minutes for 48 Inc, Hewlett, NY) with radiofrequency on the cutting and hours immediately after surgery and then 4 times a day for coagulation mode, or carbon dioxide laser set on the con- a total of 4 days. Topical antibiotic drops were instilled into tinuous mode (Figure 1 through Figure 4). each eye 4 times a day along with antibiotic ointment into The previously marked skin orbicularis oculi muscle each eye at bedtime for a minimum of 2 weeks after sur- flap was excised with a handheld cautery, electrocautery gery. No systemic antibiotics were prescribed.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 RESULTS Patient age at the time of surgery ranged from 53 to 77 years (mean age, 65.2 years) (Table 1). Thirteen patients had bilateral eyelid facial dyskinesia without significant lower facial involvement and 1 patient (patient 14) had hemifacial spasm (Table 1 and Table 2). Mean subjective improvement was 66.75% (n = 5) in the limited myectomy group compared with 58.33% (n = 9) in the other 9 patients who underwent blepharoplasty only (n = 5) and/or levator advancement (n = 4). The single patient with hemifacial spasm received 2 injections after surgery. He had difficulty quantifying the percentage of improvement, but improvement was noted at the time the study was concluded. There were no significant surgical complications in any of the 14 patients. Improved cosmesis and upper- eyelid symmetry were noted by all patients and the surgeon. All patients stated that the surgery improved their condition and cosmesis and all would have repeat surgery (Figure 4 and Figure 5). One patient with severe dry eye experienced recurrent erosion that was treated successfully with topical lubricants and did not recur after subsequent injections. The mean dose of botulinum toxin was 37.1 U prior to surgery and 33.9 U after surgery. The mean number of injections was 6.1 prior to surgery and 8.7 after surgery. The mean follow-up period Figure 1. Excision of pretarsal orbicularis muscle after dissection of skin orbicularis muscle flap from underlying tarsus.

Figure 3. After all the orbital septum adhesions are lysed and the preaponeurotic fat pad is dissected from the overlying orbital portion of the Figure 2. Excision of strip of preseptal orbicularis muscle adherent to fused orbicularis muscle, the preseptal portion of the pretarsal orbicularis muscle orbital septum and levator aponeurosis, which allows exposures and and the orbital portion of the orbicularis muscle are dissected in 1 band from facilitates reinsertion of the levator aponeurosis. overlying skin up to the eyebrow tissues.

A B C

Figure 4. A 66-year-old Vietnamese woman (patient 12) with bilateral blepharospasm and increased heaviness of eyelids before (A) and after (B and C) limited myectomy and upper-eyelid blepharoplasty.

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©1999 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 was 30.5 months for all patients after surgery. The av- Table 1. Response of Patients With Facial Dyskinesia erage duration of effect of botulinum toxin was 122.1 days to Botulinum Toxin and Eyelid Surgery* prior to surgery and 210.5 days after surgery for the 13 patients with sufficient data to analyze. Data regarding Duration of Overall Subjective Patient No./ BEB Prior to Improvement per the average duration of effect from a patient who died of Age, y/Sex Surgery, y Type of Surgery Injection, % a myocardial infarction approximately 6 months after surgery were not included. The 13 other patients contin- 1/61/F 4 Blepharoplasty 65 Upper eyelids ued to receive botulinum toxin injections at the time this 2/73/F 1 Limited myectomy 80 study was concluded. Upper eyelids All patients experienced a subjective increase in pain 3/61/F 1 Limited myectomy 65 with botulinum toxin eyelid injections that resulted from Upper eyelids scar tissue induced by upper-eyelid surgery. A resis- 4/69/F 2 Blepharoplasty 65 Upper eyelids tance to injection, particularly in the pretarsal orbicu- 5/64/M 5 Blepharoplasty 45 laris muscle, was noted after all types of upper-lid sur- Upper eyelids gery, particularly limited myectomy. The resultant 6/59/F 6 Blepharoplasty 70 discomfort on injection was significantly improved by the Upper eyelids use of ice compresses prior to injection and/or topical skin 7/65/F 7 Blepharoplasty 80 Upper eyelids anesthesia with local anesthetic cream (a mixture of 2.5% 8/77/M 10 Levator advancement 50 lidocaine and 2.5% prilocaine). Blepharoplasty Upper eyelids 9/62/F 0.5 Levator advancement 50 COMMENT Right upper eyelid 10/71/M 4 Levator advancement 50 The present study of 14 patients suggests that virtually Upper eyelids any type of eyelid surgery (limited myectomy, upper- 11/64/F 4 Levator advancement 50 Blepharoplasty eyelid blepharoplasty, and levator aponeurotic advance- Upper eyelids ment) improves the subjective and, probably, the objec- 12/66/F 4 Limited myectomy 65 tive effects of botulinum toxin eyelid injections. While Bilateral upper eyelid long-term data support this contention, the limited num- Blepharoplasty ber of patients makes statistical analysis impossible. 13/53/F 2.5 Limited myectomy 65 Bilateral upper eyelid All patients stated that the improvement after sur- Blepharoplasty gery was beyond that afforded by botulinum toxin 14/68/M 11 Limited myectomy ... injections alone. All stated that they would have repeat Left upper eyelid eyelid surgery. In addition, while cosmesis was not the Blepharoplasty Right upper eyelid goal of surgery, enhanced cosmesis and eyelid symmetry were noted by all patients. *BEB indicates benign essential blepharospasm. Ellipses indicate data not Objective data show that the average duration of ef- applicable. fect of injections increased from 122.1 days prior to sur-

Table 2. Number of Botulinum Toxin Injections and Duration of Response of Patients With Facial Dyskinesia Undergoing Eyelid Surgery*

Dosage of Average Duration of Injections, No. Botulinum Toxin, U Response to Toxin, d

Patient Before After Before After Before After No. Surgery Surgery Surgery Surgery Surgery Surgery 1 8 14 29.9 30.3 142 173 2 7 7 60.7 40.6 113 119 3 9 14 28.8 29.6 78 96 4 8 13 33.9 24.1 103 122 5 17 4 31.3 30 119 200 6 1 14 40 40 120 146 7 3 19 2.5 32.5 140 231 8† 1 21 ...... 186 9 19 10 37 41.3 99 114 10‡ 7 1 39.3 . . . 129 . . . 11 10 6 53 40 65 75 12 8 3 45 45 98 129.5 13 4 6 37.5 35 105 127 14 22 2 17.5 17.5 124.6 126

*Ellipses indicate data not applicable. †Patient received only 1 injection and then opted for surgery. ‡Patient died approximately 6 months after surgery.

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Figure 5. A 68-year-old man (patient 14) with hemifacial spasm 1 month before (A) and after (B) limited myectomy and conservative upper-eyelid blepharoplasty.

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