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Treatment of Post-Facelift Facial Paralysis With Botulinum Toxin Type A

Mota, Wellington Menezes MD; Salles, Alessandra Grassi MD, PhD; do Nascimento Remigio, Adelina Fatima MD, PhD; Gemperli, Rolf MD, PhD

Plastic and Reconstructive Surgery - Global Open: August 2019 - Volume 7 - Issue 8S-1 - p 3-4
doi: 10.1097/01.GOX.0000584204.00719.e7
Aesthetic Abstracts

Universidade de Sao Paulo (USP), Sao Paulo, Brazil

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

BACKGROUND: Nerve injuries post-facelifts are rare but cause serious functional and psychological impairment of self-esteem and quality of life.1,2 Despite being temporary in most cases, facial asymmetry typically lasts for 3 months. We present a treatment protocol for post-facelift facial nerve injuries using botulinum toxin type A (BTXA).

MATERIALS AND METHODS: The study was conducted from January 2002 to June 2018. Nine patients (all female; mean age, 58 ± 8.4 years) with asymmetries due to post-rhytidectomy facial palsies were treated in the nonparalyzed side with abobotulinum toxin type A, with 6-month to 5-year follow-up. The 500-U vial was diluted in 4 ml of 0.9% saline. We considered 0.02 ml of the solution (2.5 abobotulinum toxin units) as 1 volume unit. Patients were examined after 15 days for outcomes evaluation. The dose applied to each muscle group1 varied from 1 to 2 volume unit per point. Patients were retreated after 5–6 months in case of asymmetry recurrence.

RESULTS: Four patients sought early care (mean, 14.2 ± 6.4 days postoperative, ranging from 5 to 21 days). The others arrived later (mean, 225 ± 80.7 days postoperative, ranging from 150 to 360 days). Two patients had lesions affecting the upper third of the face, and symmetry was achieved after unilateral treatment of the frontalis muscle. Three patients had injury in the middle third; their treatment depended of analysis of the deviation vectors when smiling and frowning, as to decide which muscle groups should be treated (vertical: upper lip lifter muscles; upper oblique: lifters of the angle of the mouth muscles; and horizontal: risorius muscle). Four patients were affected in the lower third (inferior deviation vectors) and were treated with 2 points to paralyze the lower lip depressor muscles. Correction of asymmetry was achieved in all cases. Recovery from the nerve injury and BTXA application occurred symmetrically in both sides of the face in the following months. All patients with early onset of BTXA therapy (<30 days) had complete recovery of facial symmetry with a single application, evidence of neuropraxis. Patients with lesions of the upper third, those with late onset of BTXA treatment (>30 days), and those with >1 affected nervous branch presented definitive lesion, with partial recovery or improvement, and needed BTXA treatment every 6 months.

CONCLUSION: Most facial nerve injuries post-facelifts presented favorable evolution for spontaneous resolution, except in the upper third of the face and in case of late lesions. Symmetry was achieved in all cases with low doses of BTXA in the suggested protocol points, avoiding an unhappy asymmetric patient in the following months.


1. Salles AG, Toledo PN, Ferreira MC. Botulinum toxin injection in long-standing facial paralysis patients: improvement of facial symmetry observed up to 6 months. Aesthetic Plast Surg. 2009;33:582–590.

2. do Nascimento Remigio AF, Salles AG, de Faria JCM, et al. Comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA at the 1: 3 conversion ratio for the treatment of asymmetry after long-term facial paralysis. Plast Reconstr Surg. 2015;135:239–249.

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.