Objective: To investigate the efficacy of botulinum toxin injection (BoNTA) in correcting eyebrow asymmetry in patients with hemifacial spasms (HFS).

Background: HFS typically affects women in their fourth to fifth decade, often causing ipsilateral eyebrow lifting, known as the other Babinski sign (BBS), resulting in eyebrow asymmetry. While BoNTA injection effectively controls spasms, its impact on refining eyebrows remained underexplored.

Method: A retrospective cohort study included HFS patients with other BBS who received BoNTA injections from November 2022 to December 2023. All injections were administered by movement disorder specialists at the sites indicated in Figure 1A. Outcome measures were compared between before and after 1 month of BoNTA injection. The primary outcome was eyebrow shape, assessed using four parameters (Figure 1B): eyebrow peak differences (PD), eyebrow peak to eye distance (PE), palpebral fissure (PF), and eyebrow length (EH). Secondary outcomes included facial symmetry, evaluated using the House Brackmann Grading System (HB) and Sunnybrook facial nerve grading system for resting and voluntary parts (SB-R and SB-V). Patients and a blinded investigator rated overall facial asymmetry improvement, with patients also rating overall spasm improvement, considered a secondary outcome.

Results: Forty-six HFS patients (35 females and 11 males; mean age 61.46 ±11.74) participated, with an average disease duration of 10.13±5.51 years. Primary outcomes significantly improved after BoNTA injection (Table 1): PD and PE were significantly increased (p<0.001 and p<0.00), while PF and EH decreased significantly (p<0.001 and p<0.00). Facial symmetry, as measured by HB, SB-R, and SB-V scores, also significantly improved (p<0.001, p<0.001, and p<0.001, respectively). Figure 2 illustrates examples of HFS patients before and after BoNTA injection in our study. 93.5% of HFS patients achieved overall facial asymmetry improvement (Table 2), with substantial inter-rater reliability (Cohen’s kappa of 0.643). Additionally, overall spasm improvement was 78.37 ± 4.48%.

Conclusion: BoNTA treatment in HFS patients offers aesthetic benefits by refining eyebrow appearance, improving overall facial symmetry, and concurrently reducing spasms.

Figure1

Figure2

Table1

Table2

References: 1. Pawlowski M, Gess B, Evers S. The Babinski-2 sign in hemifacial spasm. Mov Disord. 2013 Aug;28(9):1298-300.
2. Stamey W, Jankovic J. The other Babinski sign in hemifacial spasm. Neurology. 2007 Jul 24;69(4):402-4.
3. Xiao L, Pan Y, Zhang X, Hu Y, Cai L, Nie Z, Pan L, Li B, He Y, Jin L. Facial asymmetry in patients with hemifacial spasm before and after botulinum toxin A treatment. Neurol Sci. 2016 Nov;37(11):1807-1813.

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