Often one comes across patients with Facial Spams in the OPD, often presenting various baffling obstacles as What, When and How to Treat ? Following 10 Reckoner points as OTPs to improve the understanding of the spectrum of facial spasms, their management and a quick guide to correct painless Botox injection treatment.

#OTP1  Knowing the type of Facial Spasms

Imaginarily divide the face into 4 quadrants – Vertical and horizontal mid – lines. Observe the quadrants in which the facial spasms are occurring

Orbicularis Myokymia

Hemifacial Spasm(HFS)

Benign Essential Blepharospasm(BEB)

Meige Syndrome

Brughel Syndrome

#OTP 2: Hemifacial Spasm (HFS): Always request for an Imaging : MRI BRAIN

Etiology of Hemifacial Spasm can have a central cause

– Ectatic cranial vasculature (Compression of the facial nerve root by an ectatic blood vessel (most often anterior inferior cerebellar artery, posterior inferior cerebellar artery, or vertebral artery) at it exits from the brainstem . Nerve damage with demyelination, resulting in aberrant signal conduction in response to nerve irritation, and thereby involuntary contraction of the innervated facial musculature.)

– Intracranial mass

– Idiopathic

#OTP 3 Counselling the patient while offering Botox(Botulinum Toxin )Injection Treatment

Since Botox is a Toxin which is neutralized in the body – effect is temporary with need for repeat injections likely every 6-8 months , duration of efficacy going down with repeat injections due to tachyphylaxis.

#OTP 4 :Must document Schirmers to rule out  Dry eye before Injection Botox – should also be repeated post Injection

#OTP 5 Botox comes as a Lyophylised powder – to be reconstituted with NORMAL SALINE

#OTP 6 Storage of Botox

Before reconstitution – Keep in the Freezer

After reconstitution : Keep at 4 degrees (Fridge side door) – upto a period of 30 days

#OTP 7.a Concentration of Botox

Botox comes as a 50units/100Unit Vial – desirable concentration is 1.25 or 2.5 Units/0.1 cc in a 1 cc syringe – So if u have a 50 units vial – diluting it with 4 cc Normal saline will give u the concentration of 1.25 Units/0.1 cc – this will help you titrate your injection dosage per 0.1 cc injection using a 1 cc syringe.

#OTP 7.b Careful Reconstitution as Botox is a delicate molecule 

– Let the vacuum in the Botox vial suction in the Normal saline rather than injecting – hold the plunger of the syringe

– Inject along the side of the vial, avoid frothing

– Gentle rotation of the vial to mix

#OTP 8 Sites of Injection – Observe the muscle with maximum spasms and injec


– For Eyelid : Inject into the Pretarsal rather than the Preseptal part of Orbicularis

#OTP 9 Painless injection

– Apply a Surface anesthetic agent – Prilocaine cream 15-20 minutes prior at the injection sites

– Use a 1cc Syringe with a 29G/30G needle

– Stand at the head end of the patient on the same side as the side of injection to avoid obstruction by the patient’s nose – i.e stand on the Right head end for Right sided injection

– Eyelid sites – Inject subcutaneously (into the Pretarsal Orbicularis) under lateral traction with the non dominant hand – direction of needle being parallel to the skin

– Forehead : Slightly higher dose – Pinch the injection site between thumb and index finger of the non dominant hand and inject – direction of the needle being oblique

#OTP 10 Dose of Botox Injection for Facial Spasms

Orbicularis Myokymia 10-15 Units
 Hemifacial Spasm  15-25 Units
Benign Essential Blepharospasm 30-40 Units
Meige Syndrome 50 Units

References :

  1. Leyngold, I., Berbos, Z., Georgescu, D., & Anderson, R. L. (2012). Essential blepharospasm and hemifacial spasm. In Smith and Nesi’s Ophthalmic Plastic and Reconstructive Surgery (pp. 345-354). Springer, New York, NY
  2. Rosenstengel, C., Matthes, M., Baldauf, J., Fleck, S., & Schroeder, H. (2012). Hemifacial spasm: conservative and surgical treatment options. Deutsches Ärzteblatt International, 109(41), 667.
  3. N. Naik, Charles N.S. Soparkar, R. Murthy, S.G. Honavar Indian J Ophthalmol 2005;53:279-288

Dr. Nupur Goel
MBBS, MS, FLVPEI (Comprehensive & Oculoplasty)
Cataract & Oculoplasty Surgeon

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