Botulinum Toxin

Before jumping into getting botulinum toxin for the face, we really need to understand what we’re messing with.  I believe that the facial muscles and their connection to the brain, are the most highly evolved of all human bodily functions.  Firstly, what are the functions of the face?Most practitioners of botulinum toxin approach the face as two halves.  The upper half that is more forgiving, and the lower half that requires more caution.  Mobility of the lower face is essential to clear speech and enunciation. The muscles around the mouth and cheeks keep a tight seal at the lips to prevent drooling and are major components in the process of eating and drinking.

What is under appreciated however is that there are similarly important autonomic functions for the upper half of the face as well.  The eyelids move to protect our precious eyes from the environment, and automatically adjust their positions in response to what the eyes sense.  In dry and windy conditions, the orbicularis muscles tighten the aperture to minimize mucus membrane exposure. Sudden bursts of light similarly cause an immediate reflexive closing of the eyes to shield the retina from photo-toxicity.  Although complications from botulinum toxin injections in the upper face are relatively mild and rare, they nearly always involve eyes.

I believe however that the most sophisticated function of our faces is in communication. The face is the single most visible portion of our bodies, especially for this Seattle’s winter.  As an ophthalmologist, I am acutely aware that our eyes are our windows to the world. But as an oculoplastic surgeon, I have learned to appreciate how the muscles and skin around the eyes serve as the window into our souls. They are the focus of gaze during conversations with other people and even animals. We have evolved to “read” eyes and are surprisingly good at it. Everyone knows that the difference between a true smile and a fake one is in the eyes.

Botulim toxin injections were first approved by the FDA for human use by an ophthalmologist who injected the substance into the muscles on the eyes to straighten strabismus.  It was first approved for cosmetic purposes in the muscles around the eyes at the glabellar folds. Since then use of the chemical has spread to all areas of the face. In Shanghai, we even injected it into the masseter muscles of the jaw for aesthetically pronounced jowls. The technique however to apply it to the facial muscles truly requires some appreciation for not just the anatomy, but also for how they work in dynamic facial expression. Although commonly used to reduce the visibility of dynamic wrinkles, there is growing use of botulinum toxin to aesthetically alter the balance of facial expressions. By minimizing the contractions of typically negative expressing muscles, the face at rest develops a more positive and confident pose. The downside however is that when the “negative” expressions are attempted, the balance can be some what abnormal appearing. Unfortunately there is give and take in everything, even for botulinum toxin.

I have helped to write a review article with my Cleveland Clinic colleague and mentor regarding the medical and aesthetic uses for botulinum toxin injections around the eyes and face. Further details to come upon publication.

Apraxia of Eyelid Opening

This is the article that Dr John Burns and I wrote for the Benign Essential Blepharospasm Research Foundation newsletter (2005:24;9-10)

Mixed Benign Essential Blepharospasm and Apraxia of Eyelid Opening.

The New Missed Diagnosis

In the 16^th Century, Flemish artist, Brueghel painted “De Gaper” which depicted a subject with markedly distorted facial features and eyelid spasms.  This is generally considered to be the first recorded case of benign essential blepharospasm and is in fact what we would now sub categorize as Meige syndrome.  From that time until the mid 1980’s, benign essential blepharospasm and Meige syndrome was a relatively unknown facial disease rarely diagnosed correctly by physicians and even less frequently treated appropriately.

In 1981, the beloved founder of BEBFR Society, Maddie Lou Koster decided that she would bring the disease out into the open and make the diagnosis and its signs and symptoms as familiar to the medical community as the common cold.  All neurologists, ophthalmologists, and neurosurgeons would certainly concur that she was immensely successful.

In 1990, Dr. Rick Anderson with the support of the BEBRF mailed out 4,000 questionnaires to patients who registered prior to 1988 with the Benign Essential Blepharospasm Foundation, of which 1,653 were returned.  One of the questions was, “how many physicians did you see prior to the establishment of a correct diagnosis?”  At that time, the average response was four physicians with the range between 1 and 75.  The cost of misdiagnosis, unnecessary studies, and unsuccessful therapy was staggering and in one percent of patients exceeded $50,000.  It is my personal experience that in the past few years virtually all patients referred to my office for treatment of benign essential blepharospasm and Meige syndrome have been correctly diagnosed by either the first or second doctor consulted for their symptoms.  Furthermore, most patients are seen within six months of the onset of their symptoms as opposed to my experience in the late 1980’s when most patients had had their disease for many years and were in the advanced stages of the syndrome.  It is apparent that the past two decades have seen a marked improvement in the efficiency of diagnosing and managing benign essential blepharospasm and Meige syndrome.

Conversely, mixed benign essential blepharospasm with apraxia of lid opening is in my experience rarely initially diagnosed by the examining physician.  Moreover it is even missed by those physicians specialized in the management of this condition, including ophthalmologists and neurologists.  Apraxia of lid opening was first described by Goldstein and Cogan in 1965 as “a non-paralytic motor abnormality characterized by the patient’s difficulty in initiating the act of lid elevation.”  Apraxia is generally defined as the inability to carry out purposeful movements in the absence of motor paralysis, sensory loss, or ataxia.  To paraphrase the definition of apraxia of lid opening, it is a patient who reports, “I can’t will my eyes to open.”

Just as blepharospasm and Meige syndrome were only gradually recognized to be relatively common diseases, mixed benign essential blepharospasm and apraxia of lid opening has also been statistically found to be a relatively common variant blepharospasm.  In 1990, David R. Jordan, Rachel Anderson, Katherine B. Digre, evaluated patients who were referred to them with the diagnosis of benign essential blepharospasm or Meige syndrome.  As they followed these patients from diagnosis, initial treatment, and in some cases surgical management, it became apparent that 7 patients (7%) of this population actually had apraxia of lid opening in addition to their referring diagnosis.  None of these seven patients were correctly diagnosed at the time of the initial visit despite these physicians’ sophisticated attempts to diagnose the mixed condition.  Between 1988 and 1992, Dr. P. Krack and M.H. Marion in the Department of Neurology, University of Giessen, Germany evaluated 195 patients with benign essential blepharospasm or Meige syndrome and of that number, 20 were later diagnosed as also having apraxia of lid opening.  These twenty patients represent a comparable 10% incidence of mixed disease among their blepharospasm patients. 

In the classical presentation, benign essential blepharospasm occurs in a woman with an average age of 55 who initially notices increased blinking and sensitivity to light.  This is followed by increasingly frequent intermittent forceful eyelid closure. 

( The spasms of the corrugator supraciliaris muscle and procerus muscles draw the brows medially and inferiorly from their normal position. )

In Meige syndrome, she would have also developed spasms of the mid and lower face.  Both of these syndromes are frequently associated with varying degrees of dry eye syndrome.    

Apraxia of lid opening can occur in association with blepharospasm, but may occur rarely in isolation.  In the “pure” form, the patient experiences sustained periods of time when she is unable to will her eyes open.  During these episodes, the eyes are fully closed.  In contrast to benign essential blepharospasm and Meige syndrome however, there is no evidence of orbicularis activity and the brows are markedly elevated by the frontalis muscles, as would be expected in someone straining to open her eyes.   In the fully developed clinical picture of mixed blepharospasm and apraxia of lid opening, the patient presents with a combined pattern beginning with sustained spasms of the procerus and corrugator muscles lowering the brow as well as the orbicularis muscles squeezing the eyes shut.  The patient eventually has relaxation of those muscles resulting in an elevation of the brows, but still lacks the ability to open the eyes.  This sequence of events is difficult to observe unless the physician has a very high index of suspicion.

The diagnosis of apraxia of lid opening is established by the use of the most common and effective treatment for benign essential blepharospasm, Botox.  The patient should initially be treated utilizing the protocol each physician has found most successful for their benign essential blepharospasm patients.  Most patients return in three months for a reevaluation and adjustment of therapy.  The typical patient with mixed disease however will return reporting that they have not appreciated improvement from the Botox treatment.  In this situation, re-treatment is indicated followed by an evaluation two to four weeks later, at which time the maximal Botox effect should be apparent.  Adequate paresis is achieved when the patient demonstrates an inability to constrict the upper and lower lids against the resistance of the physician’s fingers.  In the patient with apraxia of lid opening, there are periods of persistent involuntary lid closure despite adequate Botox treatment of the orbicularis and brow depressor muscles.  The patient will usually demonstrate brow elevation in a futile attempt to open the lids.  Patients often report that gently elevating the lids open with their fingers or touching the skin on their temple can sometimes break the attacks.  When the episode resolves, there is no evidence of ptosis or levator muscle weakness. 

It has been uniformly observed by physicians with an interest in mixed blepharospasms that traditional blepharospasm treatments are ineffective in improving the apraxia of lid opening.  Specifically, Botox, adjunct oral medications, and both limited and complete myectomies do not improve apraxia of lid opening.  Apraxia of lid opening, however, can be successfully managed after control of the patient’s blepharospasm with surgical frontalis suspension.  This is a commonly performed and successful eyelid elevating operation in appropriately chosen patients.  The tethering of the brow to the lid with this procedure is believed to bring the relief achieved by patients who break the attacks with their fingers.  In patients with mixed disease, it can be combined with a limited myectomy procedure that removes orbicularis muscle from the lids to provide improved control of both conditions.

In conclusion, mixed blepharospasm and apraxia of lid opening is a relatively common cause of the inability to maintain open and functional eyelids and is probably present in at least 7% of patients with blepharospasm.  It is also likely the reason for a significant number of treatment failures.  Observation of a patient’s eyebrows throughout the complete cycle of eyelid closure, attempted reopening, and then full normal opening, are the key to early diagnosis and appropriate treatment.