Treatment of pseudoptosis secondary to aberrant regeneration of the facial nerve with botulinum toxin type A

Purpose: To report on low-dose minimal injection treatment using botulinum toxin A for pseudoptosis secondary to aberrant facial nerve regeneration. Methods: A retrospective chart review was carried out on 16 consecutive patients with pseudoptosis secondary to aberrant facial nerve regeneration who received botulinum toxin A injections. Results: Study patients include 6 men and 10 women with median age of 65 years (range 34-78). Etiology of facial nerve palsy included Bell palsy (11), surgical injury (2), trauma (2), and Ramsay-Hunt syndrome (1). Mean duration of facial nerve palsy was 8.5 years (1.1-30). Mean duration of pseudoptosis was 6.8 years (0.5-29). Botulinum toxin A (Botox; Allergan) injections were given in the medial and lateral pretarsal upper eyelid orbicularis oculi with some patients also receiving a central and/or additional lateral injection. Mean number of injections was 2.6 (2-4). Mean total dose was 10.3 units (5-20). Subjective improvement of symptoms at follow up was noted in all cases. Margin reflex distance in all patients showed statistically significant (p < 0.001) mean improvement of 1.6 mm (0.5-2.5) during orbicularis oris contracture. No side effects were reported, and all patients desired repeat injections. Repeat injection was performed at 3- to 6-month intervals, with most patients (12) returning every 3 months. Mean follow up was 12.2 months (3-61). Conclusions: Using low doses of carefully injected botulinum toxin A into the upper eyelid can provide safe and successful treatment of pseudoptosis due to aberrant facial nerve regeneration.