OnabotulinumtoxinA versus Surgery: Evaluating Patient Treatment Choices for Postparalysis Facial Synkinesis

Treatment selection for postparalysis facial synkinesis (PPFS) is a multifaceted decision for patients. This study aimed to identify patient factors influencing treatment choice between chemodenervation with onabotulinumtoxinA alone and synkinesis surgery.

PPFS patients presenting between 2009 and 2024 were grouped into those choosing only chemodenervation and those choosing synkinesis surgery. Excluded were untreated patients and those without qualifying photographs at least 16 months after paralysis onset. Electronic Facial Paralysis Assessment was used to quantify synkinesis severity. The primary outcome was choice of treatment type, and the secondary outcome was time from synkinesis diagnosis to surgery. Each outcome was analyzed for associations with patient characteristics using univariable and multivariable analysis.

Of 549 PPFS patients, 231 patients met inclusion criteria. Factors independently associated with selecting surgical treatment included living more than 100 miles from the authors' institution ( P < 0.001) and moderate or severe synkinesis ( P = 0.010). Time from synkinesis diagnosis to surgery was significantly longer for female patients compared with male patients (adjusted mean difference, 441 days; P = 0.025) and for non-White patients compared with White patients (adjusted mean difference, 355 days; P = 0.042). Other variables, including socioeconomic vulnerability, were not found to be independently associated with selection or timing of treatment.

Patients living farther from the authors' institution and those with more severe synkinesis were more likely to choose surgical synkinesis treatment over chemodenervation alone. The time from synkinesis diagnosis to surgery was significantly longer for female compared with male patients and for non-White compared with White patients.