| | Botulinum Toxin for the Correction of Asymmetric Crying FaciesAccepted 30 April 2009. The clinical hallmark of asymmetric crying facies (ACF) is a symmetric appearance of the oral aperture and lips at rest, but significant depression of one side of the lower lip with animation (crying or smiling). ACF can resolve spontaneously in the first year of life, but surgical intervention may be required at some point to ensure a good cosmetic outcome. The authors report on the successful use of botulinum toxin type A to achieve temporary facial symmetry in two children with ACF with results lasting up to six months and suggest that such treatments may be helpful in providing more time to consider and/or plan surgical intervention.
Asymmetric crying facies (ACF) is caused by agenesis or hypoplasia of the depressor anguli oris muscle on one side of the mouth, with an incidence of approximately one per 160 live births.1 Also known as congenital unilateral lower lip palsy or congenital hypoplasia of the depressor anguli oris muscle, ACF is characterized by deformity of the lower lip. Aplasia or hypoplasia of the facial muscles is probably of primary origin, but may be secondary, with degeneration resulting from denervation.
The clinical hallmark of ACF is a symmetric appearance of the oral aperture and lips at rest, but significant depression of one side of the lower lip with crying or smiling. The diagnosis of ACF can easily be established clinically. The differential diagnosis of ACF must be made from paralysis of cranial nerve VII with electrophysiologic techniques. ACF is an isolated finding in most cases; however, it is well known that this anomaly is frequently associated with cardiovascular, head and neck, musculoskeletal, respiratory, gastrointestinal, central nervous system, or genitourinary pathology. ACF can present as a single aesthetic defect or as a hallmark of several congenital malformations. If the etiology is determined to be developmental, a search for any associated malformations and close follow-up are indicated.
ACF can resolve spontaneously in the first year of life if it is caused by facial nerve compression. However, surgical intervention may be required at some point to assure an aesthetic outcome. Passive treatments, such as weakening the unaffected side by selective marginal mandibular neurectomy or cessation of the depressor anguli oris muscle, are possible options. Surgical intervention for ACF has been reported only rarely,2 but other procedures for lower lip correction in unilateral facial paralysis can be applicable for treating this condition.3, 4
Botulinum toxin type A (BTX-A) is a presynaptic neuromuscular blocking agent that can produce selective muscle weakness when injected intramuscularly in minute quantities. BTX-A is currently used for cosmetic and therapeutic purposes and has been employed in the management of various disorders, including dystonias, facial and generalized muscle spasms, autonomic disorders, migraine headaches, and involuntary movement disorders. BTX-A can also be used for aesthetic purposes to achieve symmetry in congenital and acquired unilateral facial paralysis by weakening the contralateral side.5, 6, 7, 8, 9 We report two case studies documenting the successful use of BTX-A to correct ACF.
Patients  A four-year-old boy was referred from the pediatric neurology department for facial asymmetry. A physical examination revealed that his face had no noticeable asymmetry at rest, but the patient showed characteristic asymmetry when smiling or crying. Other facial movements were normal and there was no other congenital malformation. The diagnosis of left-side ACF was determined clinically. Eight units of BTX-A (Botox; Allergan, Irvine, CA) diluted with 2 mL of saline solution without preservatives per 100 U of the active product were injected intramuscularly using 30-gauge 0.5-in needles (13.3 mm) in the right-side depressor anguli oris muscle. The procedure was performed after alcohol asepsis of the area to be treated. One week after BTX-A injection, facial symmetry was achieved (Figure 1). A schematic view of the depressor anguli oris and injection site is shown in Figure 2. Note that the paralyzed side is the side that does not contract before the injection. A 16-month-old girl was referred from the pediatric neurology department with right-side ACF. All signs were similar to the first patient, except that the opposite (left) side was affected. A mild sedative was administered and a topical anesthetic cream was applied to the side to be injected two hours before treatment. Six units of BTX-A were injected into the opposite side. Facial symmetry was noted 10 days later (Figure 3; Video 1; video can be found online at www.aestheticsurgeryjournal.com). Discussion There are eight different serotypes of botulinum toxin; type A is the most potent and the most commonly used clinically. Many studies confirm the safety and efficacy of BTX-A in a variety of clinical indications. BTX-A is contraindicated in cases of allergy to the drug or its components, infection at the site of injection, pregnancy or breastfeeding (US Food and Drug Administration category C), and in patients with unrealistic expectations or emotional distress. In the 20 years since the clinical use of BTX-A began, there have been only rare reports of major systemic hypersensitivity reactions after treatment for any indication. Local complications such as pain, edema, erythema, ecchymosis, headache, and short-term hyperesthesia can be associated with the injection site. Unwanted side effects can be minimized—and the beneficial effects maximized—with a thorough understanding of facial soft tissue anatomy, proper patient selection, and administration of the lowest effective dosages with minimal volume.10, 11 In our patients, BTX-A injection achieved facial symmetry that lasted for a period of six months. The most important issue for us was whether or not the child's age was a restrictive factor. BTX-A is used extensively to treat children for many indications.12, 13, 14, 15, 16, 17, 18 Moreover, there are no confirmed serious side effects for the fetus when treating pregnant patients.19, 20, 21, 22 However, it must be stated that this does not mean that BTX-A can be injected during pregnancy. Psychosocial difficulties, social inhibition, and introversion in children with craniofacial conditions are common and well defined in the literature. Social introversion or inhibition is often associated with other emotional and behavioral problems, and the shunning of social activities may lead children to be aggressive, defensive, or shy.23, 24 For reconstructive procedures, such as cleft lip and palate repair or infant skull surgery, the benefits of early treatment are usually quite clear. However, in elective procedures such as treatment of ACF, the choices may be less obvious. If the child is being teased or feels that he or she does not belong, parents should probably consider surgery to improve the emotional health and self-esteem of the child. Some institutions offer initial surgery to correct ACF at two years of age or older, which is considered to be the age at which potential for recovery without intervention is no longer realistic. It is well recognized that feelings about self-image tend to change with maturity and that elective cosmetic procedures or cosmetic surgery should never be forced on a child or adolescent. BTX-A can be helpful in providing additional time to consider or plan possible surgery. Pretreatment sedation, the use of a topical anesthetic, and very thin needles can render the procedure more tolerable for children. Conclusions In two cases, ACF was successfully treated with BTX-A injection. Treatment with BTX-A can offer temporary correction of ACF, with results lasting up to six months. Acknowledgment The authors thank Paul Manson, MD, for his guidance and assistance with this article.
Web Extra Material
References 1.
1
Akcakus M
, Koklu E
, Narin N
, Kose M
.
Clinical and microscopic hair features of griscelli syndrome associated with asymmetric crying facies in an infant
.
Pediatr Dev Pathol
. 2008;11:63–65
.
CrossRef
2.
2
Udagawa A
, Arikawa K
, Shimizu S
, et al.
A simple reconstruction for congenital unilateral lower lip palsy
.
Plast Reconstr Surg
. 2007;120:238–244
.
CrossRef
3.
3
Yavuzer R
, Jackson IT
.
Partial lip resection with orbicularis oris transposition for lower lip correction in unilateral facial paralysis
.
Plast Reconstr Surg
. 2001;108:1874–1879
.
MEDLINE |
CrossRef
4.
4
Arden RL
, Sinha PK
.
Vertical suture plication of the orbicularis oris muscle: a simple procedure for the correction of unilateral marginal mandibular nerve paralysis
.
Facial Plast Surg
. 1998;14:173–177
.
MEDLINE |
CrossRef
5.
5
Collins A
, Jankovic J
.
Botulinum toxin injection for congenital muscular torticollis presenting in children and adults
.
Neurology
. 2006;67:1083–1085
.
CrossRef
6.
6
Watts C
, Nye C
, Whurr R
.
Botulinum toxin for treating spasmodic dysphonia (laryngeal dystonia): a systematic Cochrane review
.
Clin Rehabil
. 2006;20:112–122
.
MEDLINE |
CrossRef
7.
7
Yoshimura DM
, Aminoff MJ
, Olney RK
.
Botulinum toxin therapy for limb dystonias
.
Neurology
. 1992;42:627–630
.
MEDLINE 8.
8
Carruthers J
.
The treatment of congenital nystagmus with Botox
.
J Pediatr Ophthalmol Strabismus
. 1995;32:306–308
.
MEDLINE 9.
9
Kwak CH
, Hanna PA
, Jankovic J
.
Botulinum toxin in the treatment of tics
.
Arch Neurol
. 2000;57:1190–1193
.
MEDLINE |
CrossRef
10.
10
Vartanian AJ
, Dayan SH
.
Complications of botulinum toxin A use in facial rejuvenation
.
Facial Plast Surg Clin North Am
. 2003;11:483–492
.
Full Text |
Full-Text PDF (271 KB)
|
CrossRef
11.
11
Ferreira MC
, Salles AG
, Gimenez R
, Soares MF
.
Complications with the use of botulinum toxin type A in facial rejuvenation: report of 8 cases
.
Aesthetic Plast Surg
. 2004;28:441–444
.
CrossRef
12.
12
Gill C
, Covington C
, Padaliya B
, Newman W
, Pomeroy T
, Charles PD
.
Successful treatment of childhood spasticity secondary to cerebral palsy using Botox
.
Tenn Med
. 2003;96:511–513
.
MEDLINE 13.
13
Bakheit AM
.
Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres
.
Eur J Neurol
. 2003;10:415–419
.
MEDLINE |
CrossRef
14.
14
Bhakta BB
, Roussounnis SH
.
Treating childhood hyperhidrosis with botulinum toxin type A
.
Arch Dis Child
. 2002;86:68
.
CrossRef
15.
15
Rayner SA
, Hollick EJ
, Lee JP
.
Botulinum toxin in childhood strabismus
.
Strabismus
. 1999;7:103–111
.
MEDLINE |
CrossRef
16.
16
Stacy M
, Jankovic J
.
Childhood dystonia
.
Pediatr Ann
. 1993;22:53–58
.
MEDLINE 17.
17
Scott AB
, Magoon EH
, McNeer KW
, Stager DR
.
Botulinum treatment of childhood strabismus
.
Ophthalmology
. 1990;97:1434–1438
.
Abstract 18.
18
Pascual-Pascual SI
.
The study and treatment of dystonias in childhood [in Spanish]
.
Rev Neurol
. 2006;43(suppl 1):S161–S168
.
19.
19
de Oliveira Monteiro E
.
Botulinum toxin and pregnancy
.
Skinmed
. 2006;5:308
.
MEDLINE |
CrossRef
20.
20
Bodkin CL
, Maurer KB
, Wszolek ZK
.
Botulinum toxin type A therapy during pregnancy
.
Mov Disord
. 2005;20:1081–1082
.
MEDLINE |
CrossRef
21.
21
Newman WJ
, Davis TL
, Padaliya BB
, et al.
Botulinum toxin type A therapy during pregnancy
.
Mov Disord
. 2004;19:1384–1385
.
MEDLINE |
CrossRef
22.
22
Cersósimo MG
, Bertoti A
, Roca CU
, Micheli F
.
Botulinum toxin in a case of hemimasticatory spasm with severe worsening during pregnancy
.
Clin Neuropharmacol
. 2004;27:6–8
.
MEDLINE |
CrossRef
23.
23
De Sousa A
.
Psychological issues in oral and maxillofacial reconstructive surgery
.
Br J Oral Maxillofac Surg
. 2008;46:661–664
.
Abstract | Full Text |
Full-Text PDF (101 KB)
|
CrossRef
24.
24
Lahat E
, Heyman E
, Barkay A
, Goldberg M
.
Asymmetric crying facies and associated congenital anomalies: prospective study and review of the literature
.
J Child Neurol
. 2000;15:808–810
.
MEDLINE |
CrossRef
 Reprint requests: Tonguc Isken, MD, Cumhuriyet Mahallesi, Sahil Caddesi, Plaj Yolu, Izmit, 41100 Kocaeli, Turkey
DISCLOSURES The authors have no financial interest in and received no compensation from manufacturers of products mentioned in this article. PII: S1090-820X(09)00349-5 doi:10.1016/j.asj.2009.08.017 © 2009 The American Society for Aesthetic Plastic Surgery, Inc. Published by Elsevier Inc All rights reserved. | |
|
FULL TEXT00349-5/journalimage?img=PIIS1090820X09003495.fx1.lrg.gif&fig=&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
00349-5/journalimage?img=PIIS1090820X09003495.fx2.lrg.gif&fig=&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
00349-5/journalimage?img=PIIS1090820X09003495.fx3.lrg.gif&fig=&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
00349-5/journalimage?img=PIIS1090820X09003495.gr1.lrg.gif&fig=fig1&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
00349-5/journalimage?img=PIIS1090820X09003495.gr2.lrg.gif&fig=fig2&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
00349-5/journalimage?img=PIIS1090820X09003495.gr3.lrg.gif&fig=fig3&kwhquery=&issn=1090-820X&ishighres=false&allhighres=false&free=yes','journalimage');)
