This is a retrospective review of 27 patients with benign essential blepharospasm who had become resistant to treatment with botulinum toxin and had therefore undergone orbicularis myectomy of the upper lids. The study compares the dose and frequency of botulinum toxin treatment before and after the myectomy procedure. Three patients needed no further botulinum toxin injections, and the remaining patients required a significantly smaller dose to the upper lids to achieve the same effect compared with their pre-surgery regimens. Furthermore the frequency of injections was also significantly less, reducing from every 10.1 weeks to every 15.7 weeks on average. The authors assessed the cost implications based on Medicare data and found that patients undergoing surgery cost over $11,000 less to treat over a 10 year period than those who persisted with injections alone. This is an interesting paper supporting the use of myectomy for blepharospasm patients who become resistant to botulinum toxin. The vast majority of patients still require on-going injections, but less frequently and with a smaller dose. It would be interesting to know if the same was true in non-resistant patients. The authors do not mention any side-effects from the surgery, but do admit that a weakness of their study was that a formal assessment of patient satisfaction was not performed. Other confounding factors are the simultaneous ptosis surgery and the subjective criteria to determine the efficacy of the botulinum toxin treatment. Despite these weaknesses, the study provides useful evidence for the efficacy and cost-effectiveness of myectomy surgery.