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BackTable / ENT / Article
Synkinesis Treatment: Surgery, Exercises, Botox & More
Julia Casazza • Updated Mar 6, 2024 • 49 hits
Synkinesis is a type of non-flaccid facial paralysis that consists of involuntary hyper and hypokinetic movements following injury to the facial nerve. First-line synkinesis treatment consists of physical therapy exercises and neuromodulator injections (i.e. Botox and Dysport). Patients desiring longer-term results should consider synkinesis surgery, including myectomy, neurectomy, and selective neurolysis. Want to learn more? Keep reading to hear how Vanderbilt University facial plastic surgeon Dr. Shiayin Yang approaches this clinical challenge.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• First-line synkinesis treatment includes physical therapy exercises and neuromodulator injections (i.e. Botox and Dysport). Physical therapy exercises helps patients better control their muscles of facial expression. Neuromodulator injections weaken hyperkinetic muscles.
• Synkinesis treatment (neuromodulator injection and physical therapy exercises) should be continued in perpetuity.
• Synkinesis surgical options include myectomy, neurectomy, and selective neurolysis. None of these options are curative, but they can alleviate symptoms and reduce the frequency with which patients need neuromodulator injections.
• Often mischaracterized as a “disease of vanity,” synkinesis has profound effects on patients’ mental health. Treatment targeting facial paralysis and asymmetry can improve patient well-being.
Table of Contents
(1) Synkinesis Treatment with Physical Therapy Exercises & Neuromodulator Injections
(2) Surgical Options to Treat Synkinesis
(3) The Impact of Synkinesis on Patient Well-Being
Synkinesis Treatment with Physical Therapy Exercises & Neuromodulator Injections
Synkinesis involves both hyper and hypokinetic muscle activity. Thus, first-line synkinesis treatment includes physical therapy exercises to help patients use facial muscles, and neuromodulator injection to weaken overactive muscles. Neuromodulators used for injection include Botox (onabotulinumtoxin A) and Dysport (abobotulinumtoxin A). Injection sites vary based on disease involvement. Common sites include the mentalis, platysma, corrugators, and orbicularis oculi. Electromyography (EMG) compares neural activity between diseased and unaffected sides and can provide real-time feedback as the surgeon injects. Risks to injections include ptosis, asymmetry, and dry eye. Most patients require repeat injections every three months.
[Dr. Shiayin Yang]
Once someone has come to see me after a Bell's palsy diagnosis and they did the synkinesis, the first thing I recommend is physical therapy. A lot of time they'll work with the physical therapist first before they will come to me for some type of Botox therapy. Usually, it'll be physical therapy exercises and then we'll all work in coordination with the physical therapist to do Botox therapy or neuromodulator therapy. What that is doing is just weakening the overactive muscles and trying to give them symmetry as well as improved function of their face.
That treatment we do every three months. We actually have a clinic at Vanderbilt, it's our synkinesis clinic where that's all we do for a full week is just treating synkinesis patients with Botox therapy. The great thing as well that we're doing in our clinic is we're using EMG-guided Botox therapy. We're actually using an EMG machine to listen to the muscles and to determine one, it helps just precisely locate the muscles we want to treat. Then second, we can hear how does that muscle sound compared to the unaffected side and give us an idea of does it seem like this is kind of their issue that they're having. It just gives us a little bit more information as to injecting patients without the EMG machine.
[Dr. Ashley Agan]
How quickly do you move to doing Botox after starting physical therapy exercises? Is there a set time or it just depends?
[Dr. Shiayin Yang]
Sometimes the physical therapist will say, "I want a couple of sessions to work with this patient before we start Botox therapy." Other times they'll be like, "You can start." Usually, they'll work with them a time or two before we start Botox.
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Surgical Options to Treat Synkinesis
Though not curative, surgical management of synkinesis improves facial aesthetics and reduces the frequency of Botox injections. Patients who are good candidates for surgery are those who have stable paralysis and a consistent response to Botox treatments. Typically, these patients are at minimum two years out from their initial injury and one year out from initiation of Botox.
Surgical options for synkinesis include myectomy, neurectomy, and neurolysis. Myectomy – permanent surgical injury to a specific muscle – can reduce hyperkinesis of one specific muscle. In cases where multiple muscles are involved, selective neurectomy – permanent surgical injury to a specific nerve – works better. Neurolysis is a specific type of neurectomy that traces nerve branches and then selectively ablates them. Surgeons can give patients an idea of what surgical results would look like by injecting 1% lidocaine into the muscle they intend to target.
[Dr. Shiayin Yang]
They also have to be someone who's like if they're happy with Botox and they're happy with that treatment, then we just stay the course. If it's someone who's like, "I really want to do everything I can. I want to try--" because these procedures are not without risk. If it's a patient who wants to try things that are out there, then I discuss with them the risk and benefits. In terms of selective neurectomy or selective neurolysis, I typically choose patients similarly to the myectomy who've been on large amounts of Botox, who have severe synkinesis, and who are motivated and willing to try other procedures to help improve their synkinesis.
There have been studies out previously about selective neurectomy around the eye where patients still needed Botox afterwards or it seemed like those procedures weren't as successful. I think we still need a lot of data yet around these surgeries to really determine how successful they are and how long-lasting, but it can help. I do tell patients that you'll likely still need Botox afterwards, but it may decrease the amount that you need and it may help improve your symmetry and function. I think there's still a lot of research that needs to be done and data collected to fully understand what is the best treatment for these patients.
In addition to Botox to determine if they're good candidates, you can also use local to simulate the effect of what it would have in the office. It's not perfect, but it can give you an idea of how cutting a nerve in this area affect their smile or the symmetry of their face.
The Impact of Synkinesis on Patient Well-Being
Most synkinesis literature describes functional and aesthetic consequences. However, Dr. Yang cautions clinicians to understand how the condition takes a toll on patients’ overall well-being. In her experience, facial paralysis causes patients to shy away from activities that involve taking photos – a distinct challenge in the age of social media. Interested in caring holistically for synkinesis patients, Dr. Yang’s current research includes investigation into the prevalence of anxiety and depression among individuals with the condition.
[Dr. Ashley Agan]
We've covered a lot of stuff. I think key take-home points refer early and that there are a lot of options for these patients and that it's not just a disease of vanity and that it really does cause quality of life issues.
[Dr. Shiayin Yang]
Yes. I guess the last thing I'd like to just emphasize is the mental health effect it can have on patients. It's so drastic how it can affect their life. It's your face and you can't hide that. Just the effect that it has on patients is devastating. Even just the effect of Botox, that can make such a big improvement with patients. Especially now how digital our world is and how big of an influence social media is, it breaks my heart when patients tell me, "Oh, I don't take photos or I hide and I don't want to be involved." It's just one of the things that I think we can make such a big improvement and really just affects every person's everyday life.
There's that also large component. We've recently been studying just what we think is the incidence and effect of anxiety and depression in this patient population. I think that's an important thing for providers to understand as well as how this may affect them aside from just how they look and how they function, but also their mental health and well-being.
Podcast Contributors
Dr. Shiayin Yang
Dr. Shiayin Yang is an assistant professor of facial plastic and reconstructive surgery with Vanderbilt University in Nashville, Tennessee.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, December 26). Ep. 151 – Navigating Synkinesis: From Diagnosis to Comprehensive Care [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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