What is the treatment for nasolabial fold twitching?

Treatment of Nasolabial Fold Twitching

Botulinum toxin injection is the treatment of choice for nasolabial fold twitching, which represents a focal dystonia or hemifacial spasm affecting the facial nerve distribution.

Initial Diagnostic Approach

The first step is determining the underlying cause of the twitching:

• Hemifacial spasm: Unilateral, involuntary, intermittent spasmodic contractions of muscles innervated by the facial nerve, typically starting in the eyelid and progressing to involve the lower face including the nasolabial fold region 1, 2, 3
• Focal facial dystonia: Dystonic movement disorders in the cranial-cervical region characterized by uncontrollable squeezing movements, typically presenting in the fifth and sixth decades of life 1
• Post-facial paralysis synkinesis: Abnormal involuntary movements following facial nerve injury, where nasolabial fold twitching occurs as part of synkinetic movements 4

Primary Treatment: Botulinum Toxin Injection

Botulinum toxin injection is the first-line treatment and has largely supplanted surgical intervention for facial movement disorders including hemifacial spasm and focal dystonias 1.

Evidence for Botulinum Toxin:

• Successfully treats bilateral hemifacial spasm with excellent outcomes 3
• Effective for focal facial dystonias and movement disorders 1
• Reduces synkinetic movements in post-facial paralysis patients, with significant decreases in botulinum toxin dosage requirements after definitive treatment 4

Treatment Protocol:

• Inject directly into the affected muscles around the nasolabial fold region
• Repeat injections are typically needed every 3-4 months
• Dosage should be titrated based on response and side effects

Secondary Treatment Options

For Hemifacial Spasm Refractory to Botulinum Toxin:

Neurovascular decompression surgery should be considered when:

• Botulinum toxin provides inadequate relief
• Imaging reveals vascular compression of the facial nerve 2
• The anterior inferior cerebellar artery (AICA) is the offending vessel in most cases 2

Important surgical considerations:

• Compression may occur at the root exit zone (REZ) or at distal portions of the facial nerve 2
• Great care must be taken not to stretch the internal auditory arteries during AICA manipulation to prevent postoperative hearing loss 2
• If decompression at the REZ fails, examine and decompress distal portions of the facial nerve 2

For Post-Facial Paralysis Synkinesis:

Modified selective neurectomy of the buccal and cervical branches of the facial nerve provides long-term improvement when:

• Botulinum toxin requirements are high or frequent
• Patient desires definitive treatment 4

Expected outcomes from selective neurectomy:

• Significant improvement in nasolabial fold depth at rest and with smile 4
• Reduction in midfacial synkinesis 4
• Decreased botulinum toxin dosage requirements post-surgery 4
• 17% revision rate with temporary oral incompetence in 11% of patients 4

Clinical Pitfalls to Avoid

• Do not ignore bilateral involvement: Bilateral hemifacial spasm exists and presents with asymmetric, asynchronous facial contractions starting unilaterally (typically left eyelid) with the opposite side affected years later 3
• Do not assume all twitching is benign: Obtain imaging (MRI) to evaluate for vascular compression, particularly tortuous vertebrobasilar arteries 3
• Do not overlook distal nerve compression: If surgical decompression at the REZ fails, vascular compression of distal portions of the facial nerve may be responsible 2