title: Paradoxical use of frontalis muscle and the possible role of botulinum a toxin in permanent motor relearning.
abstract: OBJECTIVE
  To report 7 patients with paradoxical use of the frontalis muscle despite postsurgical correction of ptosis with good postoperative eyelid position. Successful treatment with botulinum A toxin facilitated motor relearning and cessation of muscle contraction.
  
  
  METHODS
  Interventional case series.
  
  
  METHODS
  Seven patients, in 2 eye-plastic clinics, who underwent successful surgical correction of upper eyelid ptosis.
  
  
  METHODS
  Review of clinical history, clinical photographs, treatment, and follow-up.
  
  
  METHODS
  Frontalis muscle contraction and upper eyelid position.
  
  
  RESULTS
  Patients underwent successful surgical correction of ptosis but continued using the frontalis muscle despite good eyelid position postoperatively. Frontalis contraction ceased spontaneously in 2 patients, but required botulinum A toxin injection in 5. The effects of a single treatment of botulinum A toxin lasted from 3 months to 2 years, longer than the expected effect of the toxin.
  
  
  CONCLUSIONS
  Patients with long-standing eyelid ptosis may paradoxically continue utilizing the frontalis after successful surgical correction and despite good postoperative eyelid position. Cessation of frontalis contraction can be achieved with a single injection of botulinum A toxin. We hypothesize that chemodenervation, achieved with the toxin, may influence the central nervous system to relearn the set point for muscle contraction and may be associated with permanent motor relearning. Spontaneous resolution of muscle contraction can occur in the first months after surgery.
authors.affiliation: Jules Stein Eye Institute and Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. guybensimon@gmail.com
authors.forename: Guy J
authors.initials: GJ
authors.lastname: Ben Simon
authors.forename: Sean M
authors.initials: SM
authors.lastname: Blaydon
authors.forename: Robert M
authors.initials: RM
authors.lastname: Schwarcz
authors.forename: Tanuj
authors.initials: T
authors.lastname: Nakra
authors.forename: Robert A
authors.initials: RA
authors.lastname: Goldberg
authors.forename: John D
authors.initials: JD
authors.lastname: McCann
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019882:Blepharoplasty; D001763:Blepharoptosis / Q000503:physiopathology* / Q000601:surgery; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D005152:Facial Muscles / Q000187:drug effects* / Q000503:physiopathology; D005260:Female; D006801:Humans; D007273:Injections, Intramuscular; D008297:Male; D008875:Middle Aged; D009048:Motor Skills / Q000502:physiology; D009119:Muscle Contraction / Q000502:physiology*; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D009801:Oculomotor Muscles / Q000187:drug effects* / Q000503:physiopathology; D011597:Psychomotor Performance / Q000502:physiology*
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A