BackTable / ENT / Podcast / Transcript #151

Podcast Transcript: Navigating Synkinesis: From Diagnosis to Comprehensive Care

with Dr. Shiayin Yang

In this episode, host Dr. Ashley Agan discusses management of synkinesis with Dr. Shiayin (Shi) Yang, facial plastic surgeon at Vanderbilt University Medical Center. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Defining Synkinesis

(2) Causes of Synkinesis

(3) Evaluating Patients with Synkinesis

(4) Physical Therapy & Botulinum Toxin Injections for Synkinesis

(5) Myectomy, Selective Neurectomy & Selective Neurolysis for Synkinesis

(6) Preventing Exposure Keratopathy in Synkinesis Patients

(7) The Mental Health Effects of Synkinesis

Listen While You Read

Navigating Synkinesis: From Diagnosis to Comprehensive Care with Dr. Shiayin Yang on the BackTable ENT Podcast)

Ep 151 Navigating Synkinesis: From Diagnosis to Comprehensive Care with Dr. Shiayin Yang

00:00 / 01:04

More about this episode

Stay Up To Date

Follow:

Subscribe:

[Dr. Ashley Agan]
This week on The BackTable Podcast.

[Dr. Shiayin Yang]
I really want to do everything I can. I want to try because these procedures are not without risk. If it's a patient who wants to try things that are out there, then I discuss with them the risk and benefits. In terms of selective neurectomy or selective neurolysis, I typically choose patients similarly to the myectomy who've been on large amounts of Botox, who have severe synkinesis, and who are motivated and willing to try other procedures to help improve their synkinesis.

[Dr. Ashley Agan]
Hi, everybody. Welcome to The BackTable ENT Podcast. We're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by. My name is Ashley Agan, I'm a general ENT. I'll be your host today, and we have a great guest talking about synkinesis today. We have Shi Yang. She's an assistant professor of facial plastic surgery at Vanderbilt University Medical Center in Nashville, Tennessee. She completed her otolaryngology head and neck training at Loyola University in Chicago, and then her fellowship in facial plastic and reconstructive surgery at University of Michigan.

She specializes in cosmetic and reconstructive surgery of the face. She has a special clinical interest and research interest in facial nerve paralysis. Welcome to the show, Shi.

[Dr. Shiayin Yang]
Thanks, Ashley, for having me.

[Dr. Ashley Agan]
We always like to start off the show just giving you a chance to just tell us a little bit about yourself, your background, your practice.

[Dr. Shiayin Yang]
Yes, so I have been in practice, now I am on my fifth year at Vanderbilt in Nashville, and it's been a great practice. I get to do the breadth of facial plastics, including cosmetic surgery, reconstructive surgery, and being at a tertiary medical center, I'm able to work with a lot of different partners, so, neurotologist, head and neck surgeons, I'm really going to see a lot of different complex cases. I think that's a lot of where we see a lot of facial nerve paralysis and management of these patients, as well as just trying new technologies and surgeries to help treat these patients in terms of the cutting edge.

I think that's a huge benefit of being in a large academic center and is exciting because you're really just sharing with colleagues and figuring out how can we best manage these patients.

(1) Defining Synkinesis

[Dr. Ashley Agan]
I feel like facial nerve paralysis can sometimes fall across lots of different disciplines. When, first of all, setting the stage, can you just talk about synkinesis from a definition standpoint, like what is that? What does that look like?

[Dr. Shiayin Yang]
Sure. I think this is a great question that you asked, and it's something that I tell my residents and fellows a lot is that synkinesis is actually part of a spectrum, which is called post-paralytic facial paralysis or non-flaccid facial paralysis, and it occurs after there's any type of facial nerve injury. I think a lot of people hear synkinesis and they think it's something that happens just after Bell's palsy, but it can happen after any type of injury to the nerve.

If there's been traumatic injury after like temporal bone trauma, or if the nerve has been transected during surgery due to a malignancy, like a parotid malignancy, or if it's stretched or injured during removal of acoustic neuroma, you can get synkinesis after these situations as well, or these scenarios, and I think that's something that is important to understand. Synkinesis itself, the definition is involuntary movement of facial muscles with voluntary facial movement.

If you're thinking-- more commonly you see a patient and they say, "Every time I close my eye, my mouth moves, or every time I smile, I get a contracture in my neck, or my eye closes," that's our fundamental thinking of what synkinesis is, but really this picture of this non-flaccid facial paralysis is a combination. You can have synkinesis where patients are having this involuntary movement of the facial muscles, but you can also have this mixed picture where some patients have weakness. Usually we'll see that a lot in the lower lip. They'll have elevation of their upper lip and their DAO [Depressor Anguli Oris] is not contracting to bring that for that dental show of their lower lip, and so you're not getting that natural smile.

Some patients will have this hyperkinesis or they're contracting more on a certain part of the face, and so they'll have these deep nasolabial folds. They'll complain of significant tightness or pain around the neck. It's more a constellation of symptoms and signs that's included in synkinesis that patients can have after any type of facial nerve injury.

(2) Causes of Synkinesis

[Dr. Ashley Agan]
That's really helpful because I feel like you're right. When I think about it, I just think of like the Bell's palsy patient that has that involuntary eye movement or something when they smile. You paint the picture of this being a much more broad, much more diverse group of patients. When speaking of etiologies, anything that can affect or damage the facial nerve can lead to synkinesis, it sounds like. What are you seeing, in your practice, what's the most common patient presentation?

[Dr. Shiayin Yang]
The most common patient presentation is Bell's palsy. I think that is why this podcast is so important and education is so important because a lot of the patients I see develop synkinesis much later. Synkinesis can develop anywhere between 6 to 18 months after your initial injury. You get Bell's palsy, let's say you recover movement of your face, you see your primary care provider or whoever it is that was managing it and they're like, "Oh, well, your facial function is back." Then six months later, you start noticing these involuntary movements or you're having issues with eye function or smile, speaking, eating, and you may not be following with that person anymore.

Or you follow with that person and they say, "Well, there's nothing I can do, your face is moving-- it's not moving perfectly, but it's moving." I see so many people years out after a diagnosis saying, "Oh, I was told there was nothing that could be done." Really, it's important to educate both patients, but also providers that there's a lot that can be done. It doesn't just stop at, "Well, they regain function back of their face." There's so much more that can help. Another thing is a lot of patients come to me, and it's really sad because they're just like, "Oh, well, I thought this was vain, my smile is not correct, but I thought it was just vanity and so I really wasn't seeking treatment for it."

It's not just the aesthetic of how your face is working, but it's also how it functions. I've had some people who are very resistant to receiving Botox therapy, but once I educate them that there's a lot of functional components to it as well, they realize that benefit once they've been treated.

[Dr. Ashley Agan]
6 to 18 months, wow. That can be a long time after that initial facial paralysis presentation. I've also had patients similarly who they're like, "Is this going to be considered elective? Is this considered cosmetic?" You have to like talk about that, "No, this is still considered a medical problem that should be covered."

[Dr. Shiayin Yang]
Yes, exactly. It's both. I think improving the awareness [of synkinesis] for everyone will make such a big difference. There's so much we can do. Aside from just the functional aspect of it, there's a huge psychological component too, because patients just tell me, "I don't go out, I don't eat, I don't see my friends, I quit my job." It's just heart-wrenching because there's so much that we can do for these patients, but the awareness is just not there. The understanding of what can be done, we just need to help educate people so that we can provide the treatments that they need.

[Dr. Ashley Agan]
When you're talking to your patients or colleagues, as far as like when you need to see patients that are experiencing this, for example, if I'm the primary care doctor seeing the Bell's palsy patient and they've regained their facial movement at three months, but then they come back at that six month mark, and they are having some synkinesis, is it like refer right away? Like go ahead and just send them straight to a facial plastic surgeon like yourself, or does the timeliness of the referral, does that make a difference?

[Dr. Shiayin Yang]
I say refer right away. I think most importantly is timeliness of treatment. Bell's palsy is a diagnosis of exclusion. You want to rule out every other cause possible that could be causing this facial weakness. I do see a lot of patients who are diagnosed with "Bell's palsy," and it's actually maybe a facial nerve neuroma or a latent malignancy metastasis to the facial nerve. There's other causes.

I don't expect everyone to understand those other causes, but if it doesn't seem consistent with Bell's palsy, then you have to do further workup for these patients. You can't just throw this label on a Bell's palsy, which is the most common diagnosis that I see and I think one of the most common diagnosis for facial nerve paralysis. I think referring them and getting them in as soon as possible is helpful because then you can have a specialist who really treats these patients.

It's not that if it's a true diagnosis of Bell's palsy and I see you in the office, I may not be throwing a procedure or treatment on right away, but it's more being able to follow them, and if they do develop some type of sequelae from this paralysis that I know how to treat you or what type of options to be able to offer you.

[Dr. Ashley Agan]
When you're talking to your Bell's palsy patients or any patient who might be experiencing synkinesis, how do you explain it to patients when they're like, "Why is this happening?" How do you explain that underlying pathophysiology of nerve rewiring, direction kind of thing?

[Dr. Shiayin Yang]
That's an excellent question. That's a huge part of just the treatment algorithm and plan and education with these patients is. Unfortunately, since we don't know how the nerve regenerates, we don't have a perfect treatment for it. All of our subsequent treatments for facial nerve paralysis is based on what the patients are experiencing and not actually fixing. We don't truly understand the pathophysiology. Since we don't 100% know the pathophysiology, we don't know how to restore them back to their pre-paralysis state.

It's understanding that and really setting expectations that I'm going to do my best to give you the best smile you need or help you close your eyes best as possible. It is very difficult, well, near impossible to get you back to where you were before. That's a huge part of the understanding. Next, I discussed that the most common theory in terms of pathophysiology is there's some sort of aberrant rewiring of the nerve as it's growing back to its distal branches. The facial nerve, as we know, comes from the brainstem, routes through temporal bone out into the parotid gland, and then branches into multiple branches onto the face to innervate the multiple facial muscles that there are.

Since there's so many branches, there's different ways that the nerve can regenerate down those different paths. That is the most common reason how synkinesis occurs. There's also thoughts that there's also a remapping or rerouting cortically. There's been studies to demonstrate that there's different areas within the brain after a facial nerve paralysis. That's why I think physical therapy is extremely important because you also need to retrain your brain how to activate certain muscles. Physical therapy plays a huge role just helping patients looking in the mirror, biofeedback, realizing, "Oh, I need to do this or that in terms of a facial function."

Until we really truly understand how the nerve regenerates, we're not going to have the perfect solution. I also think that's a great reason why facial nerve paralysis is such an exciting field because there's so many different areas of research that we can go through and there's so many potential new options to help improve these patients' outcomes.

(3) Evaluating Patients with Synkinesis

[Dr. Ashley Agan]
That's exciting. Going back to our patient that's presenting to your office, what additional workup needs to happen as you're seeing these patients? Do you think of them in different buckets, like your Bell's palsy patient versus your post-traumatic or surgical injury patient? Do you think of them differently?

[Dr. Shiayin Yang]
Yes. That's a great question. It depends on the type of presentation they're coming with. If it's a flaccid facial palsy, so their entire side of their face isn't moving, and I know the etiology of their paralysis, then I'd lump them into one bucket and discuss what is our timing in terms of if I think the nerve will regenerate or if they need some type of reanimation procedure. I would put known etiology, flaccid facial paralysis in one bucket.

In another bucket, if it's an unknown etiology with the presumptive diagnosis of Bell's palsy, and these patients could either be completely flaccid, meaning one side of the face isn't working, or they could have the mixed-picture synkinesis where they're having involuntary movement, maybe weakness additionally, or hyperkinesis. Those patients, if the etiology of their injury is not clear, then really history and physical is your biggest tool in these patients.

Full head and neck exam, looking at doing a good otologic exam, making sure there's nothing within the middle ear or within the ear that could be causing the spatial nerve paralysis, looking at their parotid gland, any history of skin cancer, doing a full head and neck exam to make sure there's no lesions or bumps, and then doing a neurologic exam as well as a full cranial nerve exam. History is important because that's going to clue you in if it's, "Yes, that sounds like a Bell's palsy." These patients are sudden within 72 hours onset of partial or complete paralysis on that face.

Usually those patients say, "Hey, doc, I woke up, and the next morning my face was out." Compared to someone who's saying, "Oh, my face slowly went out, but then I regained function, and then a couple months later it got weaker again," that's an indication it's not Bell's palsy. Additionally, patients who only have partial weakness of one branch or two branches, that should also be an indication that maybe these aren't Bell's palsy patients. Anyone who's had recurrent facial paralysis on one side or bilateral facial paralysis, that is very rare with Bell's palsy.

Or if it's someone who said, "Oh, I was diagnosed with Bell's palsy," they're seeing you four to six months later and their face is completely out. Those are warning signs that it's not Bell's palsy, and in any of those cases, you should do additional workup. If it seems like it's the pretty straightforward Bell's palsy diagnosis, sudden onset, no other warning signs, then typically you do not need additional workup for those patients. We have a great guideline put out by the Academy in terms of Bell's palsy that can really help guide providers just on what's the current recommendations by the Academy.

Typically I won't do additional workup unless I'm concerned or something seems off. If I'm concerned, then it's an MRI IAC with contrast to look at the full course of the facial nerve. Sometimes I'll additionally get labs just to see if there's other causes that could be leading to this paralysis.

[Dr. Ashley Agan]
Does their recovery, like if they recover fully versus recovering partially, does that affect your decision to get imaging?

[Dr. Shiayin Yang]
If they are still flaccid, so completely paralyzed after three to four months of their initial onset, then I will get an MRI. If they've got some movement, then yes. If they're starting to show some recovery, then usually I won't. I would say if there is any doubt or if you're unsure, get the MRI and make sure there's nothing else that's causing it. Because if there is something else, then essentially, especially with the reanimation options, time is of the essence.

[Dr. Ashley Agan]
For your patients who've had a nerve injury during surgery, like for example if they have a big parotid tumor and you have to sacrifice the nerve, how does that presentation fold into your algorithm for this?

[Dr. Shiayin Yang]
If it's someone who's had injury of the facial nerve because of surgery, it will depend on-- there's actually a lot of factors that play into effect. Ideally, I would like to treat those patients upfront. At the time of the resection, I want to do a cable graft at the same time to repair the nerve because that's your best shot at improving their outcomes. If they come to me afterwards, let's say they're a couple of months afterwards, it will depend on their motivation. If they want to try everything possible and they're young, then the sooner the better.

Usually, if you want to do some type of cranial nerve transfer or cable graft, you want to do the surgery before the facial muscles atrophy or you have atrophy of those motor end plates. You're looking really within 18 months. Some people will say 18 to 24 months, depending on the patient's age and comorbidities.

[Dr. Ashley Agan]
That makes sense.

[Dr. Shiayin Yang]
If the patient is older and let's say they're going to undergo radiation, chemotherapy, you can consider more static options. If you're doing static options, there's not really any time limit on that. The time is of essence when you're trying to give them some sort of dynamic reinnervation.

(4) Physical Therapy & Botulinum Toxin Injections for Synkinesis

[Dr. Ashley Agan]
Back to our synkinesis patients, after you've done your workup or you've determined how much workup needs to be done, let's say you've said, okay, seems like this is Bell's palsy and you've recovered some movement, but you're having some of this involuntary facial movement. What's next after that? What kind of treatment options do patients have and how do you think about how aggressive or conservative you need to be there?

[Dr. Shiayin Yang]
Once someone has come to see me after a Bell's palsy diagnosis and they did the synkinesis, the first thing I recommend is physical therapy. A lot of time they'll work with the physical therapist first before they will come to me for some type of Botox therapy. Usually, it'll be physical therapy and then we'll all work in coordination with the physical therapist to do Botox therapy or neuromodulator therapy. What that is doing is just weakening the overactive muscles and trying to give them symmetry as well as improved function of their face.

That treatment we do every three months. We actually have a clinic at Vanderbilt, it's our synkinesis clinic where that's all we do for a full week is just treating patients with Botox therapy. The great thing as well that we're doing in our clinic is we're using EMG-guided Botox therapy. We're actually using an EMG machine to listen to the muscles and to determine one, it helps just precisely locate the muscles we want to treat. Then second, we can hear how does that muscle sound compared to the unaffected side and give us an idea of does it seem like this is kind of their issue that they're having. It just gives us a little bit more information as to injecting patients without the EMG machine.

[Dr. Ashley Agan]
How quickly do you move to doing Botox after starting physical therapy? Is there a set time or it just depends?

[Dr. Shiayin Yang]
Sometimes the physical therapist will say, "I want a couple of sessions to work with this patient before we start Botox therapy." Other times they'll be like, "You can start." Usually, they'll work with them a time or two before we start Botox.

[Dr. Ashley Agan]
Are you using Botox specifically as your chemo denervation agent of choice and what's your-- how do you dilute it and how much are you using?

[Dr. Shiayin Yang]
Sure. At our institution, we use Botox. I also treat patients at the VA and there I use Dysport. My dilution for Botox is 2.5 units per 0.1 CC. Usually, with cosmetic Botox, I typically dilute 4 units per 0.1 CC, so it's a little bit more dilute with my synkinesis patients. I haven't seen a ton of differences between the Dysport or the Botox. Occasionally you'll have a patient or two who feels like the Botox is worn off too quickly, and so then you can consider using a different type of neuromodulator therapy.

[Dr. Ashley Agan]
About how much is each muscle-- are we talking about small doses or does it depend?

[Dr. Shiayin Yang]
It depends. I'll inject all around the eye, corrugators, outer orbicularis oculi. The corrugators, I usually start out about 4 units per corrugator on each side. In terms of the orbicularis oculi, laterally, I'll do anywhere between 2.5 to even 10 units. For blepharospasm patients, you can do significantly more. I'll usually start conservatively and then grade up from there. We did have a paper out from our institution just giving our average doses of Botox therapy in our patient population, and then there was a great paper out that gives a standard amount and where to start that's safe.

Safe places would be around the eye, the platysma, the neck. Places I typically do not inject are the levators because I get worried about dropping the smile. Usually around the mouth is more difficult in terms of injection because there's so many different muscles connecting that you don't exactly know which ones may be involved. It's more high-risk territory there. Starting out safe. Even around the eye gives them huge benefit. The neck because of tightness, the mentalis. I actually usually don't do a ton around the frontalis, but I'll do a little bit if one side is just very animated and the other side they're not getting anything at all. Even just the symmetry of it gives them such an improvement.

[Dr. Ashley Agan]
As far as risks of Botox, I don't know, I think about ptosis when you're injecting around the eye. What do you talk to your patients about as far as risks?

[Dr. Shiayin Yang]
The big thing I talk to them about truthfully is that this is going to be a journey, you have to work with me for a couple of sessions before we truly get it right. It even may take more sessions. I think it's evolving, especially if you're starting to treat these patients within their first two years of facial paralysis because their synkinesis may continue to evolve and develop.

The biggest thing I counsel them is I could make certain things worse and you may not like it, but you have to work with me so we can figure out what's best for you because essentially, I'm trying to treat muscles that are working in ways that they shouldn't be and I don't know what is the best way to treat you. I don't know what's the perfect muscle to target and how much target it is. It's really tailoring the plan to each patient because each patient is unique and so their Botox plan is unique to them. That's, I think, the biggest thing I tell them up front is that this is going to take six months to a year and may even be longer just to figure out what's best for you.

Sometimes we may get it perfect and other times we may not. It's just being adaptable to that. I think it's really shown by how far our patients come to see us every three months. It's not easy. We have patients driving two hours, three hours away to come see us every three months, which is not easy for these patients, but demonstrates how important this therapy is. In terms of medical risk, ptosis is a risk, especially if you're injecting around the eye and the outer orbicularis oculi. That is a risk. You can give patients drops afterwards that can help, but usually, you'll notice the onset was about 10 days, 2 weeks. It tends to wear off a little bit sooner than Botox, which wears off in about three months.

The other biggest risk is just asymmetries around the face, especially if you're working around their smile, is having an asymmetric smile. I've also had dry eyes if you're injecting a lot around the eye, especially with patients with facial paralysis because the eye already isn't working well. Some people can have significant tearing, some can be a little bit more dry, other bruising, which is pretty temporary. Really, I think the asymmetries are the biggest risk that I talk to them about.

[Dr. Ashley Agan]
I think setting expectations is really important with anything. If they know that this is not like a one-and-done easy fix, I think that helps knowing that on the front end for sure.

[Dr. Shiayin Yang]
Yes. Agreed. Expectations are huge and just really-- I think I spend the most time talking to patients about the pathophysiology, and like I said before, since we don't know how it happens, we don't have the perfect cure. Since we don't have the perfect cure for it, this treatment is not without its faults and it's going to take a while to just get you to what you want and the state you want to be.

[Dr. Ashley Agan]
Remind me, when you're injecting around the eye, there are things that you can do to decrease the risk of causing ptosis?

[Dr. Shiayin Yang]
If you're around the eyebrow and injecting, injecting superficial and not large quantities can help decrease your risk.

[Dr. Ashley Agan]
Gotcha.

[Dr. Shiayin Yang]
It's really just knowing your anatomy, knowing where you're at, and as long as you're not deep, that will help in terms of decreasing your risk.

[Dr. Ashley Agan]
Gotcha. As far as knowing when to move on to more aggressive options-- in preparation for our talk, I read a little bit about surgeries as far as doing a specific, finding a nerve and cutting it or lysing it or cutting some muscle fibers. Can you talk a little bit about that? How often do you actually need to do that? When would you start to consider that after using Botox? What are your thoughts on that?

(5) Myectomy, Selective Neurectomy & Selective Neurolysis for Synkinesis

[Dr. Shiayin Yang]
That's a great question. That's a big area that's developing within the field. It's actually nothing new. It's been around for a while, but it's gained a lot of interest recently. The first one is myectomy, and that's cutting the muscle. Common targets are the DAO and the platysma and cutting those muscles, the goal is that you're giving these patients a little bit more symmetry. It's on exam, identifying those areas that could be treated and the patients who have had success with Botox. These are usually my longer-standing patients. I would want to wait and make sure that their synkinesis is more stable and they're not going to continue developing before I offer them surgical therapy.

They also have to be someone who's like if they're happy with Botox and they're happy with that treatment, then we just stay the course. If it's someone who's like, "I really want to do everything I can. I want to try--" because these procedures are not without risk. If it's a patient who wants to try things that are out there, then I discuss with them the risk and benefits. In terms of selective neurectomy or selective neurolysis, I typically choose patients similarly to the myectomy who've been on large amounts of Botox, who have severe synkinesis, and who are motivated and willing to try other procedures to help improve their synkinesis.

There have been studies out previously about selective neurectomy around the eye where patients still needed Botox afterwards or it seemed like those procedures weren't as successful. I think we still need a lot of data yet around these surgeries to really determine how successful they are and how long-lasting, but it can help. I do tell patients that you'll likely still need Botox afterwards, but it may decrease the amount that you need and it may help improve your symmetry and function. I think there's still a lot of research that needs to be done and data collected to fully understand what is the best treatment for these patients.

In addition to Botox to determine if they're good candidates, you can also use local to simulate the effect of what it would have in the office. It's not perfect, but it can give you an idea of how cutting a nerve in this area affect their smile or the symmetry of their face.

[Dr. Ashley Agan]
Like using Lidocaine, just Local?

[Dr. Shiayin Yang]
Yes. 1% Lidocaine and just injecting and seeing, does that give them a little bit more upturn of their oral commissure or does it help improve the symmetry of the smile?

[Dr. Ashley Agan]
For patients who you found the sweet spot and the Botox is working and let's say they don't want a surgical option, can they just expect to just come in and get their Botox every three months forever or does the muscle atrophy, does anything change or how do we know what to expect over the long run?

[Dr. Shiayin Yang]
That's a great question. So far, patients have tolerated it well. Botox has been around for quite a while with no long-term adverse effects. I do suspect there's probably some muscle atrophy, but in my experience thus far, patients still need that Botox. They've been getting treatments for anywhere between 10 and 20 years, I haven't yet seen a patient fully come off of Botox yet, but I also haven't been in practice for that duration of time. Once I get there, I'll let you know.

[Dr. Ashley Agan]
When's the earliest that you would consider a surgical intervention? If a patient is like at one year, if they're like, "The Botox works, but I'm just really tired of driving here every three months, all right, it's just not working good enough." How do you know when it's time to be more aggressive or, take that next step?

[Dr. Shiayin Yang]
To be more aggressive, I would want them at least two years out from their injury and then I would want at least a year of Botox therapy for those patients because I want to see what benefit have you gotten and where. For me, there's no point to rush anything because you're still going to need Botox afterwards. The goal is just hopefully it will decrease how much you need, and I try to set their expectations for that. I tend to be more conservative in my approach, especially because this field is still emerging and these procedures are still emerging. I want to make sure-- it's going to take a while for us to get that dose right for you. Then once I feel like we're at a steady state, we've gotten a good dose, then we could consider a surgery.

[Dr. Ashley Agan]
The Botox helps you know that you're targeting the right muscles, right?

[Dr. Shiayin Yang]
Yes. That they're getting some type of benefit and effect in that area.

[Dr. Ashley Agan]
Are they still doing physical therapy during this time too? Once they start doing Botox, are they encouraged to continue doing their physical therapy in the mirror every day?

[Dr. Shiayin Yang]
Yes. I encourage them to continue physical therapy because the Botox can also affect how your muscles are reacting. I want you to keep doing those exercises, keep doing those therapies. They don't necessarily have to be seeing the therapist. Once they've learned the exercises, they can do them at home.

[Dr. Ashley Agan]
Every day for, I don't know, 30 minutes or 15 minutes, they're looking in the mirror and practicing moving their face?

[Dr. Shiayin Yang]
Correct, as much as they can. If you think about ourselves and if you've ever done physical therapy, it's when you can do it.

[Dr. Ashley Agan]
With the surgical options, how do you decide if you want to do the myectomy versus neurectomy or neurolysis?

[Dr. Shiayin Yang]
It depends on what the myectomy is. It's usually limited to a certain muscle. If I think that certain muscle is-- they would get benefit, I would offer them myectomy versus if it's more severe around the face, then you can offer the neurectomy. Myectomy is targeting like if they have the downturned corner of their mouth and with Botox or with a Lidocaine injection, they show upward excursion of the oral commissure, then I'm like, "Oh, you'd be a good candidate for a myectomy," or they have this super tight band on their neck and they have a lot of tightness, then you'd be a candidate. Whereas if a lot of parts of the face are involved, then you can consider the neurectomy.

[Dr. Ashley Agan]
Gotcha. When you're doing the myectomy, are you coming through the muscle completely, are you coming through partially?

[Dr. Shiayin Yang]
You're cutting the muscle completely.

[Dr. Ashley Agan]
Then you just let it be and it won't try to heal back together or anything?

[Dr. Shiayin Yang]
Yes, you let it be and you try to take a large amount of it so it doesn't-

[Dr. Ashley Agan]
Do you take out a little piece?

[Dr. Shiayin Yang]
A chunk of it.

[Dr. Ashley Agan]
Okay. Gotcha.

[Dr. Shiayin Yang]
Piece of it.

[Dr. Ashley Agan]
With your neurolysis, are you tracing out the nerve from-- Where do you-

[Dr. Shiayin Yang]
Tracing out the distal branches of the nerve and then stimulating the nerve to see is this branch associated with an unwanted movement. Maybe instead of the corner of the mouth going up, it's causing it to go down. Mostly looking at those ones that are down-turning the mouth then stimulating them and drop to see if it's giving you an unwanted movement and then targeting those. There's different ways that the neurectomies can be done as well in terms of cutting out a portion of the nerve, clipping the ends of the nerve. I think it's still up for debate, what are the best nerves to target and what's the best ways to cut the nerves.

[Dr. Ashley Agan]
Gotcha. Are you doing that through a facelift approach?

[Dr. Shiayin Yang]
Correct. Through a facelift incision.

(6) Preventing Exposure Keratopathy in Synkinesis Patients

[Dr. Ashley Agan]
Wow. Awesome. As we round it out, any other key points or pearls or anything that we didn't dive into that you want to make sure that we hit or do you want to talk about the surgeries anymore?

[Dr. Shiayin Yang]
Yes. I think the other important thing that I didn't talk about is when patients present initially with facial paralysis, one of the biggest things that you also want to take into account is protecting their eye. They're not able to close their eye, there's a lot of different things you can do. First, you tell them to do drops because they're not going to be blinking, drops throughout the day, ointment at night, taping of the eye.

Depending on how long you think they're going to be paralyzed, you can do an eyelid procedure. An upper eyelid weight, you can do one surgically or there also have weights that you can tape externally to the eye just so they're closing because you really want to protect that eye so it doesn't harm their vision. That's in addition to treating patients with steroids and antivirals, making sure that you're taking care of their eye. If you have any concern, just send them to an ophthalmologist to get their eye looked at and just making sure they're not getting dried out, they're not injuring the eye.

[Dr. Ashley Agan]
Yes. That's a very good point. One thing we didn't talk about also is does early treatment, like for example for Bell's palsy patient, does that decrease the chances of having synkinesis?

[Dr. Shiayin Yang]
It improves your chance of recovery and getting your facial nerve function back, so improving your overall outcomes.

[Dr. Ashley Agan]
As far as synkinesis, that can happen. You could have a full recovery of your face and still have synkinesis though, right? We don't know why some patients-

[Dr. Ashley Agan]
Yes. I feel like it does improve the synkinesis, but I'd have to look it up, to be honest. I don't know. I feel like it does.

[Dr. Ashley Agan]
What percentage of patients end up having synkinesis? Is it the majority or the minority?

[Dr. Shiayin Yang]
It varies in the literature. There's rates anywhere between 10% to 50% of patients developing synkinesis after facial paralysis. We know that treatment upfront with steroids does improve overall outcomes after injury. That's why it's recommended that you're treated with high-dose steroids upon a diagnosis with Bell's palsy.

[Dr. Ashley Agan]
It's probably hard to know because patients who have minor synkinesis, like you were saying, they probably just suffer in silence and, yes, I know they are not counted because either no one knows to refer them or they just-- like you said, they feel like maybe it's cosmetic or in vain to seek treatment. It probably is hard to know the exact numbers.

[Dr. Shiayin Yang]
Yes. We know that with conditions such as Ramsey-Hunt or if you have a complete paralysis, you have a higher risk of developing synkinesis post-paralysis. There are certain factors that are associated with higher risk of synkinesis. Awesome.

[Dr. Ashley Agan]
That makes sense. The greater the injury, the more likely you are to have that apparent rewiring. I think that makes sense.

[Dr. Shiayin Yang]
The only other thing I would mention in terms of this talk is that a lot of patients come asking about acupuncture or electrical stimulation to help with improvement of their symptoms, there's still not enough data or evidence to show if there's improvement with that. When patients come to ask me, that's what I tell them, "There's just not been enough in the literature to demonstrate if there's an improvement."

[Dr. Ashley Agan]
Also not enough to recommend against, right? It's just like a maybe, maybe not.

[Dr. Shiayin Yang]
I think a lot of the consensus in terms of electrical stimulation is that there's concerns that it could worsen it, but there are some data in other fields that show there could be potential benefit. Right now, I usually recommend just physical therapy as well as Botox therapy for these patients.

[Dr. Ashley Agan]
Gotcha. All right. I think that's been a great talk.

[Dr. Shiayin Yang]
Good. I hope it was helpful.

(7) The Mental Health Effects of Synkinesis

[Dr. Ashley Agan]
We've covered a lot of stuff. I think key take-home points refer early and that there are a lot of options for these patients and that it's not just a disease of vanity and that it really does cause quality of life issues.

[Dr. Shiayin Yang]
Yes. I guess the last thing I'd like to just emphasize is the mental health effect it can have on patients. It's so drastic how it can affect their life. It's your face and you can't hide that. Just the effect that it has on patients is devastating. Even just the effect of Botox, that can make such a big improvement with patients. Especially now how digital our world is and how big of an influence social media is, it breaks my heart when patients tell me, "Oh, I don't take photos or I hide and I don't want to be involved." It's just one of the things that I think we can make such a big improvement and really just affects every person's everyday life.

There's that also large component. We've recently been studying just what we think is the incidence and effect of anxiety and depression in this patient population. I think that's an important thing for providers to understand as well as how this may affect them aside from just how they look and how they function, but also their mental health and well-being.

[Dr. Ashley Agan]
Absolutely. I think that's a great point and a great way to bring this all together. Thank you so much for taking the time.

[Dr. Shiayin Yang]
Thanks for having me.

[Dr. Ashley Agan]
If listeners want to learn more about you, do you have a website at Vanderbilt or a social media or a plug that you want to put out there?

[Dr. Shiayin Yang]
Yes, I have both. I have a provider website at Vanderbilt and then I have an Instagram account, it's shiyangmd on Instagram for learn more.

[Dr. Ashley Agan]
Cool. Awesome. Sounds good. Thank you for taking the time.

[Dr. Shiayin Yang]
Awesome. It was nice to meet you. Thanks so much for having me.

Podcast Contributors

Dr. Shiayin Yang

Dr. Shiayin Yang is an assistant professor of facial plastic and reconstructive surgery with Vanderbilt University in Nashville, Tennessee.

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, December 26). Ep. 151 – Navigating Synkinesis: From Diagnosis to Comprehensive Care [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.