Botulinum toxin A treatment of overactive corrugator supercilii in thyroid eye disease

Abstract

Background/aim: Patients with thyroid eye disease with upper eyelid retraction often develop overaction of the accessory muscles of eyelid closure, the glabellar muscles corrugator supercilii and procerus. The resultant glabellar furrowing (frown lines) contributes to the typical thyroid facies. The aim of this study was to evaluate the use of botulinum toxin A reversible chemodenervation of the glabellar muscles as adjunctive treatment in the rehabilitation of patients with thyroid eye disease.

Methods: 14 patients (13 females) ages 39-76 years (mean 52) with inactive thyroid eye disease and associated medial eyebrow ptosis and prominent glabellar frown lines were recruited. All patients had a history of upper eyelid retraction. Each patient was treated with a single botulinum toxin injection (Dysport 0.2 ml, 40 units) into each corrugator supercilii and sometimes procerus muscles as an outpatient procedure. The effectiveness and acceptability of the treatment was assessed clinically and from a patient questionnaire.

Results: The injections were tolerated by 13/14 (93%) patients. There was resultant flattening of the glabellar region and improvement of medial eyebrow contour in all patients, with onset of paralysis within 1 week. All patients reported a subjective improvement in appearance. Side effects included one patient (7%) with reversible partial ptosis. The beneficial effect lasted 4-6 months, with a gradual return of function. Repeat treatment was indicated where there was persistent upper eyelid retraction and protractor overaction.

Conclusion: Botulinum toxin A chemodenervation of the glabellar muscles in these patients was effective and acceptable. Chemodenervation should be considered in the rehabilitation of patients with thyroid eye disease where there is upper eyelid retraction and overacting protractors resulting in a thyroid frown. Once the eyelid retraction has been successfully treated by surgery, the need for further glabella muscle chemodenervation is considerably reduced.

Figures

Figure 1

The corrugator supercilii muscles interdigitate with both frontalis and orbicularis at the medial end of the eyebrow.

Figure 2

(A) Corrugator supercilii is easily palpated by asking the patient to contract these muscles. (B) Botulinum toxin A is injected diagonally through the thick glabellar skin into the bulk of the muscle. The needle is directed medial and inferiorly. The muscle must be relaxed during the injection to reduce discomfort.

Figure 3

This 67 year old female thyroid patient had bilateral upper eyelid retraction for 5 years. Two years after bilateral Henderson's procedures, she still had prominent glabellar lines and bunching of the medial end of the eyebrows. She received botulinum toxin A injections into both corrugator supercilii and procerus muscles. After treatment she could not contract her glabellar muscles even with the greatest effort—the glabellar region remained smooth while the palpebral apertures narrowed (orbicularis oculi) and lateral nasal folds formed (nasalis) from increased facial nerve activity. These photographs show the pretreatment, early post-treatment (2 weeks) and longer term post-treatment (4 months) effects. Glabellar region: (A) Pretreatment. Relaxed. (B) Pretreatment. Actively contracting. (C) Two weeks after treatment. Relaxed. (D) Two weeks after treatment. Actively trying to contract. (E) Four months after treatment. Relaxed. (F) Four months after treatment. Actively trying to contract.

Figure 4

This 62 year old male thyroid patient had bilateral marked upper eyelid retraction for several years. Four months following bilateral levator recession he still had mild right upper eyelid retraction with marked glabellar furrows and altered eyebrow contour with bunched medial eyebrow ptosis. He received botulinum toxin A into the corrugator muscles but not procerus. After treatment the glabellar region was smoother but the established furrows were still visible. There was improvement of eyebrow contour by elevation and lateral displacement of the medial eyebrow. (A) Pretreatment. Relaxed. (B) One week after treatment. Relaxed.