Full Face and Neck Treatment With OnabotulinumtoxinA in Patients With Facial Palsy

May 2021 | Volume 20 | Issue 5 | Features | 560 | Copyright © May 2021

Published online April 12, 2021

Roberta D’Emilio MD, Teresa Salerno MD, Giuseppe Rosati MD

Villa Salaria, Rome, Italy



Facial palsy is a common problem from which many patients do not completely recover and hence have to live with chronic sequelae.1 These may include discomfort, functional deficiencies, and aesthetic defects that can have significant physical and mental consequences and a detrimental impact on quality of life.2,3

Botulinum neurotoxin type A (BoNTA) is a key tool in the management of facial palsy, reducing associated synkinesis and hyperkinesis while also improving facial balance and overall aesthetics.1,4-6 Improvements in quality of life have also been demonstrated.1,7 Furthermore, BoNTA injection is minimally invasive and repeatable, and usually associated with few major adverse events;1,4,6 hence, BoNTA may be used as part of a long-term management strategy.

Standardized protocols are currently lacking for the use of BoNTA in patients with facial palsy.3,7 Owing to the great variety of clinical presentations, every case should be assessed and treated on an individual basis. Nonetheless, it is important for practitioners to achieve some degree of systematization within their overall methodology.

We have developed a full-face and neck approach to the treatment of facial palsy with BoNTA using standardized entry points, dose ranges and injection depths (Table 1). The overall focus is on:

• Treatment of both sides of the face to ameliorate synkinesis of the affected side, minimize hyperkinesis of the unaffected side, and improve overall facial symmetry.

• Treatment not just of the face but also both sides of the neck, with the aim of obtaining a progressive rejuvenation that minimizes the negative aesthetic effects of facial palsy.

Here, we present case studies of two patients with facial hemiparesis treated with BoNTA (onabotulinumtoxinA, Allergan, Dublin, Ireland) using this approach. The standard dilution was used for all treatments (50 units of onabotulinumtoxinA in 1.25 mL of saline solution).


A 53-year-old woman presented with left-side Bell’s palsy that had developed late in pregnancy when she was 40 years old. Routine blood testing and analyses for neurotropic viruses were negative. She was treated with corticosteroids until delivery.

Since then, she has had left facial hemispasm with painful tonic–clonic contractures, particularly in the lower face. Previous attempts at drug therapy with clonazepam, pregabalin, baclofen and gabapentin yielded only temporary and partial improvements. The addition of complementary treatments, such as B vitamins, physiotherapy, acupuncture and magnet therapy, had no benefit. She was also treated with BoNTA injections 2–3 times per year, primarily in the upper third with little treatment of the mid- and lower face; the neck was not injected. This approach was largely unsuccessful.

At 47 years of age, she underwent left retromastoid microcraniectomy to solve a vascular–nervous conflict at the origin of the left facial nerve in the bulb-pontin. After surgery, resolution of hemispasm was noted in the upper third of the face, with slight persistence in the middle third, but no change in the lower third. She was subsequently treated only with BoNTA on an irregular basis. The patient self-assessed the results using the 5-point Global Aesthetic Improvement Scale (GAIS): 1 = worsened; 2 = no change; 3 = improved; 4 = much improved; 5 = very much improved. Using this scale, the change was rated as a 3, representing an ‘improved’ appearance.

The patient began treatment at our center in April 2019, based on a full-face and neck approach using onabotulinumtoxinA (Table 2; Figure 1A). Repeat treatment using a similar injection pattern was undertaken in June 2019 and October 2019. Excellent results were achieved, as shown and described in Figure 1. Results on GAIS were assessed by the patient as a 5, representing a ‘very much improved’ appearance.