First Bite Syndrome Following Rhytidectomy: A Case Report

Abstract

Background: First bite syndrome (FBS) is a known complication of parotid gland resection, parapharyngeal space dissection, and cervical sympathetic chain injury. It can be described as severe cramping or spasms in the parotid region triggered by the first bite of a meal, with the pain lessening during each subsequent bite. Although dissection for a rhytidectomy is in the vicinity of the parotid parenchyma, face-lift is not typically characterized as a procedure that can lead to FBS. Case description: A 53-year-old female underwent a deep plane face-lift to address her goals of improving jowls, nasolabial folds, and cervicomental angle. Intraoperatively, the dissection proceeded without any complications. Initially, her postoperative course was uneventful; 3 weeks after surgery, she noticed pain at the start of mastication that would improve throughout the course of a meal. She elected to proceed with observation. At 6 months after surgery, she began to experience improvement in her symptoms, and shortly thereafter had complete resolution. Discussion: First bite syndrome is a complication associated with deep lobe parotid resection, first described in 1998. The innervation of the parotid gland is complex and includes contributions from the auriculotemporal nerve, the great auricular nerve, and the cervical sympathetic chain. During rhytidectomy, dissection occurs along the parotidomasseteric fascia in order to elevate a flap of the superficial musculoaponeurotic system. Inadvertent injury to the parotid parenchyma can lead to damage to the postganglionic sympathetic fibers innervating the myoepithelial cells. Ultimately, expectant management is the mainstay of treatment and symptoms typically resolve within 6 months to 1 year. Conclusion: First bite syndrome is a complication that can be seen with a variety of facial surgeries. In the case of rhytidectomy, FBS should be considered a potential risk, as dissection into the parenchyma of the parotid gland can result in postoperative autonomic dysfunction.

Botulinum toxin A for the treatment of first bite syndrome—a systematic review

“…This systematic review examines the potential of BTA to treat FBS resulting as a surgical complication. As previously discussed, while some patients develop resolution of symptoms within 1-18 months (5,10,(19)(20)(21)(22)(23)27,52,53), up to 88% of patients continue to experience symptoms (2,5,19,24,(53)(54)(55). Botulinum toxin has had multiple applications in otolaryngology, including dystonia of the larynx (56), laryngeal granulomas (57), laryngeal joint dislocation (58), cricopharyngeal spasm (57), posterior glottic synechiae (59), blepharospasm (60), hemifacial spasm (60), temporomandibular joint disorders (61), and oromandibular dystonia (60).…”

“…This may explain the potential long-term improvements some patients experience. Finally, since resolution occurs spontaneously (10,(19)(20)(21)(22)(23), it may be that BTA serves as a bridge, treating the symptoms until time allows for natural recovery.…”

“…However, due the limited data available in the literature as discussed above, we were not able to compare the outcomes of BTA to observation only. This is an important consideration given that FBS is known to improve or resolve spontaneously (10,(19)(20)(21)(22)(23). Studies in this review utilized BTA from 2-60 months after development of FBS, which makes it difficult to parse the benefit of BTA over observation, especially in studies that started injections shortly after development of FBS.…”

“…While FBS may spontaneously resolve in 6-20% of patients (2,5,19,20) and partially improve in 69-82% of patients (2,5,20); 15-18% of patients may develop undiminished, chronic pain (5,19). The time to spontaneous resolution has been reported to be from 1-18 months (10,(20)(21)(22)(23)(24). Prior medical treatments aimed at FBS include carbamazepine with and without concomitant amitriptyline (19)(20)(21)25,26), nonsteroidal anti-inflammatory drugs (20,27), opioids (28), hyoscine (28), gabapentin (19,21), pregabalin (19,29), and local anesthetics (16,19,21,28).…”