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Video Documentation of Botulinum Toxin Treatment For Dynamic Perioral Asymmetry
Thanapoom Boonipat, BS, Mitchell Stotland, MD.
Geisel School of Medicine at Dartmouth, Hanover, NH, USA.

Title: Video Documentation of Botulinum Toxin Treatment For Dynamic Perioral Asymmetry
Authors: Thanapoom Boonipat, BS; Mitchell Stotland, MD.
Symmetry of midline facial structures is of particular importance in the assessment of facial attractiveness. Asymmetry of the mouth at rest, or during animation, may result in misinterpretation of one’s mental or emotional status and be subconsciously interpreted as a sign of cunning, contempt, or cognitive dysfunction.
Unilateral lip palsy raises significant issues because the range of lip movements are so universally involved in smiling, eating, salivary competence, kissing, crying, and routine emotional expression1. Surgical options such as static or dynamic reconstruction of the paralyzed lip, or resection of the un-affected motor nerve or mimetic muscles, involve intricate interventions with some morbidity but no guarantee of a dynamically symmetric outcome2-3.
In this clinical series we present before and after video examples of patients treated with targeted botulinum toxin type A (BTA) injections for perioral asymmetry caused by a range of etiologies: (i) Ramsey-Hunt syndrome, (ii) facial nerve injury post-resection of acoustic neuroma, (iii) Bell’s palsy, (iv) asymmetric crying facies syndrome, (v) post-traumatic marginal mandibular branch injury, and (vi) cleft lip with maxillary cant.
Pre-treatment video clips were obtained of 6 patients with unique etiologies of dynamic perioral asymmetry during animation. Treatment followed: selective BTA injections of 20-25 units to contralateral lip depressor and/or lip levator, or ipsilateral hyperactive lip levator muscles. Post-treatment videos were obtained at 6-8 weeks.
Outcomes Measured:
Gross clinical and video assessment was performed.
Four patients had isolated left lower lip palsy. One patient had palsy of the right upper and lower lip. One patient had hyperactive elevation of the right upper lip. BTA-induced paralysis of targeted muscles resulted in notable improvement of dynamic perioral asymmetry in all patients, as demonstrated by video. Untoward effects from attenuating functional muscle action was neither noted clinically nor commented on by patients. A high level of satisfaction resulted in all patients returning for multiple subsequent re-treatments.
We show through the use of a series of pre- and post-treatment videos how six unique etiologies of dynamic perioral asymmetry can be effectively treated with targeted botulinum toxin injections. The range of etiologies treated, and the video documentation of clinical outcome that we demonstrate, both expand meaningfully upon the limited prior literature in this area.
Lindsay RW, Edwards C, Smitson C, Cheney, ML, Hadlock, TA A Systematic Algorithm For The Management Of Lower Lip Asymmetry Am J Oto 32(1): 1-7 2009
Isken T, MD, Gunlemez A, Kara B, Izmirli H, Gercek H Botulinum Toxin for the Correction of Asymmetric Crying Facies Aesth Surg J. 29(6):524-527  November 2009
Benedetto AV Asymmetrical Smiles Corrected by Botulinum Toxin Serotype A Dermatol Surg 33:S32–S36, January 2007

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