A dermatologist describes how she uses fillers and, or botulinum toxin-A to restore disfiguring facial imbalances that result from Bell’s palsy.
Bell’s palsy, which affects about 40,000 Americans annually, is the most common cause of facial paralysis, according to the National Institute of Neurological Disorders and Stroke (NINDS). Washington, D.C.-based dermatologist Cheryl M. Burgess, M.D., says she sees many patients with permanent facial disfigurement from Bell’s palsy, and with neurotoxins and fillers Dr. Burgess helps to restore normal facial balance.
Cheryl Burgess, M.D.Bell’s palsy is an idiopathic facial paralysis that may be caused by a virus. Most cases resolve within six months; however, permanent facial nerve damage can occur, resulting in a permanent disfigurement of the face, Dr. Burgess says. Bell’s palsy affects men and women equally and can occur at any age, but it is less likely to occur before age 15 or after age 60. People who have it often have diabetes or upper respiratory issues, like a cold or the flu, according to NINDS.
The condition affects one side of the face, cosmetically. As a result, many patients request fillers for ipsilateral volume loss, not recognizing contralateral hyperkinetic facial muscle activity, according to Dr. Burgess.
“The impact over time causes asymmetry and disfigurement; therefore, both sides of the face are often treated to preserve facial balance,” she says.
Dr. Burgess, who spoke on the topic of cosmetic treatments for Bell’s palsy at the American Society for Dermatologic Surgery Annual Meeting,(Chicago, October 2015), explains that these patients usually present with asymmetrical faces and facial expressions and occasional speech impediment.
The condition affects people physically, emotionally and socially.
“Many complain of dry eye on the affected side and/or drooling. Reluctance to social interaction is common, especially when the people who knew them when their appearance was normal,” Dr. Burgess says.
Dr. Burgess recommends that dermatologists consider assessing the contralateral side, first.
“The hyperkinetic nature of the facial muscles on the [contralateral] side of the face can pull the paralyzed or [ipsilateral] side of the face towards it; thus, creating a twisted appearance of the perioral region,” she says. “Relaxing the hyperkinetic muscles will create a balance to the face.”
Dermatologists can minimize long-term distortion of the face if they intervene early on in a permanent Bell’s palsy condition - usually one to two years after onset, she says.
To help balance out the occasional ipsilateral facial volume loss, Dr. Burgess uses volumizing fillers, such as polylactic acid, hyaluronic acid, calcium hydroxylapatite, or fat.
Dermatologists can use botulinum toxin-A (generic) and Botox (Allergan), Xeomin (Merz), and Dysport (Ipsen) to relax the hyperkinetic muscles.
“Doses can vary depending on the degree of muscle involvement,” Dr. Burgess says. “On the average, I use from 60 to 80 units in one session on the [contralateral] side of the face, where the hyperkinetic muscle contractions occur.”
Dr. Burgess might use less in a patient whose distortion is more recent and who doesn’t have a lot of facial distortion, she says.
Use of botulinum toxin type A for Bell’s palsy is considered experimental and investigational by such carriers as Aetna, according to Aetna.com. The ICD-10 code given for facial nerve disorders/Bell’s palsy is G51.0. According to Dr. Burgess, the CPT code 64612, and the J code is J0585 medical BTX-A.
Whether for acute or chronic cases, the outcomes from using botulinum type A can be quite good. A researcher reported in 2013 in Otology and Neurotology that use of botulinum toxin after acute facial palsy is “of great value,” decreasing relative hyperkinesis contralateral to the paralysis and resulting in greater symmetric function.1
Researchers reported in Plastic and Reconstructive Surgery in May 2005, that up to 16% of Bell’s palsy patients have significant sequelae, including tightened facial muscles, with a deepening nasolabial fold and reduced palpebral fissure; blepharospasm; and nerve damage resulting in ipsilateral forehead paralysis, reduced depressor anguli oris function and poor excursion of the angle of the mouth on smiling.2
They found botulinum toxin’s effect in these patients was more apparent during facial animation and not as much when the face was static. But patients greatly appreciated the improvement in facial symmetry.
Dr. Burgess says that, in her experience, most of her patients with Bell’s palsy are being followed by their internists and, or neurologists; however, they report that their physicians have failed to discuss the possible cosmetic treatment options.
“Therefore, dermatologists should be knowledgeable about treatment options to open up a dialogue with their Bell’s palsy patients,” she says.
Disclosure: Dr. Burgess is a clinical investigator for Allergan and Merz and is on the advisory board honorarium for Allergan, Galderma, and Merz.
1. Kim J. Contralateral botulinum toxin injection to improve facial asymmetry after acute facial paralysis. Otol Neurotol. 2013 Feb;34(2):319-24. http://www.ncbi.nlm.nih.gov/pubmed/23444480
2. Bulstrode NW, Harrison DH. The phenomenon of the late recovered Bell's palsy: treatment options to improve facial symmetry. Plast Reconstr Surg. 2005 May;115(6):1466-71.http://www.ncbi.nlm.nih.gov/pubmed/15861048