Botulinum Toxin for First Bite Syndrome: A Symptom‐Guided “Follow‐The‐Pain” Injection Strategy

BACKGROUND: To evaluate botulinum toxin type A (BoNT-A) for First Bite Syndrome (FBS) and assess a symptom-guided "Follow-the-Pain" (FTP) injection strategy in patients with incomplete response to standard treatment. METHODS: Consecutive patients with postoperative FBS were treated with ultrasound-guided intraparotid BoNT-A injection. Patients with partial or poor response received additional targeted injections (15-25 U) at patient-reported sites of maximal pain using the FTP protocol. Pain intensity was assessed using a Visual Analog Scale (VAS), and outcomes were monitored with a biweekly patient diary. RESULTS: Five patients (mean age, 41 years) were included. Standard treatment resulted in marked improvement in one patient, partial benefit in three, and no response in one. The four patients with persistent symptoms subsequently underwent the FTP protocol, achieving additional pain reduction. Symptom recurrence generally required repeat treatment at 5-6-month intervals. CONCLUSIONS: BoNT-A appears effective for FBS. In patients with persistent or partially controlled symptoms, a symptom-guided FTP strategy may provide additional benefit within a stepwise management approach.