Botulinum Toxin and Surgery Offer Complementary Benefits for Facial Synkinesis, Review Finds

A systematic review published in Aesthetic Plastic Surgery found that botulinum toxin type A (BTX-A) injections and surgical interventions may serve complementary roles in managing facial synkinesis, with treatment approaches differing according to disease severity.¹

Facial synkinesis, a complication of peripheral facial nerve paralysis, involves involuntary facial movements that can affect facial function and appearance. Although BTX-A injections and surgical procedures are established management options, their comparative effectiveness and potential combined benefits remain under investigation.

Botulinum Toxin vs Surgery for Facial Synkinesis

Researchers from Clínica Universidad de Navarra in Spain systematically reviewed 24 studies evaluating BTX-A injections, surgical procedures, and multimodal approaches for facial synkinesis.

The review followed PRISMA guidelines and included searches of PubMed, Web of Science, Scopus, and the Cochrane Library. Investigators assessed risk of bias using Joanna Briggs Institute tools and evaluated evidence certainty using the GRADE framework.

Of the included studies, 11 examined BTX-A, 11 evaluated surgical interventions, and two investigated multimodal treatment approaches.

BTX-A injections improved involuntary facial movements and facial symmetry, with a favorable safety profile. However, patients required repeated injections to maintain treatment effects.

Surgical procedures, including selective neurectomy and myectomy, produced more durable structural improvements in patients with severe or refractory synkinesis. The researchers also reported that surgery could potentially reduce subsequent BTX-A dosing and treatment frequency in selected patients.

Importantly, substantial differences in patient characteristics, baseline disease severity, and treatment approaches prevented direct quantitative comparisons. The certainty of comparative evidence was rated low to very low.

The findings support further investigation of individualized, stepwise treatment strategies rather than positioning surgery and BTX-A as competing interventions.

"BTX-A and surgical interventions should be viewed as complementary tools within a stepwise treatment algorithm rather than competing modalities," the authors concluded.¹

Source

Lejarraga A, Gurpegui D, Hontanilla B. Surgical treatment and botulinum toxin type A for the management of facial synkinesis: a systematic review. Aesthetic Plast Surg. Published online November 6, 2026. doi:10.1007/s00266-026-06415-9