Half-mirror biofeedback exercise in combination with three botulinum toxin A injections for long-lasting treatment of facial sequelae after facial paralysis

Objectives/hypothesis: The present study was conducted to develop a new method for maintaining the effect of botulinum toxin treatment for facial sequelae. We used a combination strategy including the administration of botulinum toxin three times at 6-8-month intervals followed by daily newly developed half-mirror biofeedback rehabilitation for about 2 years from the first injection. Study design: This was a prospective study. Methods: Seventeen patients with unilateral facial palsy for >1 year were included in the study. The amount injected per site varied from 1.5 to 3 U. The purpose of the first injection was to reduce the most inconvenient facial problem such as facial synkinesis or hyperkinetic movement at the points of the periocular area and the zygomaticus major and minor muscles with an average dosage of 17.4 +/- 13.9 U. The second injection was to enhance facial symmetry at prominent hypertrophic areas on the contralateral side with 36.5 +/- 15.4 U, and the third injection was to add cosmetic configuration at the points of deep furrows and creases caused by facial muscular hyperkinesis or atrophy with 15.6 +/- 8.4 U. Result: After three injections of botulinum toxin A and 2 years of half-mirror biofeedback exercises, all patients showed marked relief of facial synkinesis and facial asymmetry. Before treatment, the mean +/- standard deviation (SD) Sunnybrook (SB) score was 36.8 +/- 8.76. After the first injection, the score increased by 11.4. After the second injection, the score increased by 14.6; it further increased by 15.6 after the third injection. Conclusion: This facial rehabilitation strategy, consisting of three injections of botulinum toxin and half-mirror biofeedback exercises, proceeds over the course of 2 years and offers a long-lasting cure for facial synkinesis and facial symmetry as well as improved facial aesthetics. (C) 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.