Facial paralysis is the loss of facial muscle movement due to a weakened or damaged facial nerve, usually occurring on one side of a patient’s face. Causes of facial paralysis that require surgical treatment include trauma, tumor, complication from surgery, among other causes.
Diagnosis of chronic facial paralysis is performed by a clinician. This may include electrodiagnostic testing, if the injury is recent and the prognosis for nerve recovery is unknown.
Facial Paralysis may be treated through a variety of surgical approaches. All techniques, however, share a common goal: to restore facial symmetry, improve essential functions of the face (such as speech and drinking liquids).
In cases of facial nerve paralysis that have lasted, in general, 1.5 years or less, a nearby motor nerve can be connected to a portion of the facial nerve in order to restore movement. Please see detailed descriptions of each procedure with Before and After results in the “Reanimation Surgery” section.
One of the most common nerve transfer procedures is called the nerve to masseter transfer [12]. This involves the use of the nerve to the masseter muscle as a donor nerve to supply input to the paralyzed facial nerve in order to restore a patient’s smile. Facelift-type incisions are used to access both the nerve to masseter and the main trunk of the facial nerve. The branch of the facial nerve that commonly produces a smile, the buccal branch, is carefully divided and connected to the masseteric nerve. The nerve to masseter is then connected to the facial nerve, thereby providing nerve input to the paralyzed facial nerve. After 6 months, patients will be able to initiate facial movement by biting down (activating the masseteric nerve).
Patients usually stay in the hospital for one or two days following this procedure. This is a relatively reliable method to restore movement to the corner of the mouth. In order to simultaneously provide better resting symmetry to the face, a Fascia Lata Sling or Hypoglossal nerve transfer may be performed simultaneously (see below).
Hypoglossal Nerve Transfer
Hypoglossal Nerve Transfer
Combined Hypoglossal
In order to restore resting symmetry or “tone” to the face, the hypoglossal nerve may be used as a donor nerve to resupply the injured facial nerve. The hypoglossal nerve assists with movement of the tongue. Due to the importance of tongue movement to speech and swallowing, the hypoglossal nerve is not cut completely, but is instead partially cut to allow nerves to grow into the facial nerve without sacrifice of the entire hypoglossal nerve. This typically preserves normal tongue mobility.
Dual Nerve Transfer
The main advantage of the nerve to masseter transfer is that it can restore impressive movement to the corner of the mouth. Its main weakness is that it does not provide sufficient resting tone or symmetry at rest. By contrast, the advantage of the hypoglossal nerve transfer is that it restores symmetry at rest, but movement or smile is extremely limited. Taking advantage of these strengths and limitations, the two nerve transfers may be combined together in one surgery to provide both smile reanimation and restoration of tone. In the combined hypoglossal nerve and nerve to masseter transfer, both the hypoglossal nerve and the nerve to masseter are employed simultaneously.
Gracilis Free Muscle Transfer for Chronic Facial Paralysis
The gracilis muscle transplant procedure has the ability to restore moving, functional muscle to the face. This is particularly useful in cases of long-standing facial paralysis or paresis (weakness). The procedure involves harvest of muscle from the inner thigh through a surgical incision. The gracilis muscle is detached, along with its blood vessels and nerve. The muscle is then transplanted to the paralyzed side of the face and connected to a nerve and blood vessel in the face.
Once the gracilis muscle is transplanted to the paralyzed side of the face, it must be connected to a new nerve, so that it can move the paralyzed side of the face. The gracilis muscle may be connected to the nerve to master (which is normally used for biting/chewing), to a cross-facial nerve graft harvested from the leg, or to both nerves simultaneously. These options are decided based on a discussion between the surgeon the patient. In general, the gracilis may be performed in a single surgery if connected to the masseteric nerve, or in two surgeries if connected to a cross facial nerve graft. Patients usually stay in the hospital for approximately three or four days after this surgery. The advantage of the gracilis free tissue transfer surgery is that it can, if successful, restore movement to the corner of the mouth in any patient with facial paralysis, regardless of the duration of paralysis. Nerve transfers, discussed above, are typically used only within 1-2 years from the onset of paralysis. A gracilis free muscle transfer can be used even many years after the onset of paralysis or weakness. In the case of facial weakness with some movement, but no smile, the gracilis free muscle transfer is an effective way to restore smile but also preserve whatever function is left.
Static Sling (Facelift and Sling to Support the Corner of the Mouth)
Fascia Lata
The most time-tested treatment for facial paralysis involves a facelift on the paralyzed side of the face, combined with a soft tissue from the leg that is used to hold up the corner of the mouth. In this procedure, tissue from the leg (fascia) is removed from the thigh through a surgical incision. Fascia is a form of connective tissue that wraps our muscles in a fibrous sheath. Using a facelift incision, this tissue is then attached to the muscles at the corner of the mouth and used to lift it into symmetric position. This provides relatively quick improvement in facial symmetry, speech, and helps keep food in the mouth.
Temporalis Tendon Transfer and Lengthening Temporalis Myoplasty
The temporalis muscle is situated on the side of the head, and is one of four major muscles used for chewing. It attaches to the jaw bone (mandible), and helps to close the jaw when chewing. The muscle, and its bony attachment, can be cut through a skin incision that is placed in a natural skin crease between the lip and cheek. The tendon and bone are then attached to the muscles at the corner of the mouth. This results in the corner of the mouth being pulled upwards in a more symmetric position. This procedure provides a very long-lasting suspension of the face, and immediately results in improved symmetry at rest, and often improves speech and eating. There is mild to moderate discomfort in the jaw after this procedure, but this improves with time. This is also a relatively quick procedure that can last for years.
Coronoid Process
Cross Facial Nerve Graft
Sural Nerve Graft
Paralyzed Face with CFN Graft
In some cases of facial nerve injury, a nerve graft is obtained from the lower leg. This is a sensory nerve that gives sensation to the outside of the calf and outer portion of the foot. Using this nerve causes numbness in these areas. The nerve graft can then be connected to the non-paralyzed side of the face, providing nerve supply to the paralyzed side of the face. Due to the length of these grafts, they may not provide a reliable source of nerve supply and are used only in select cases or in certain situations.
Additional Treatments
Some patients with facial weakness may benefit from a facelift (rhytidectomy) on the side of their facial paralysis. The goal of this facelift, as in all facelifts, is the elevation of redundant and drooping soft tissue near the jawline and neckline. This is not a facial reanimation surgery, but can improve resting symmetry and have a pleasing effect on the appearance of the face. Facial incisions for a facelift are shown below.
The deep tissue of the face that is often repositioned in a facelift is called the superficial superficial muscular aponeurotic system (SMAS). The SMAS is released and repositioned, in a manner called a “SMAS flap facelift” which is a well-established technique2. The SMAS flap facelift may be combined with other procedures.
[2] Pepper, J.-P. and S. R. Baker (2011). "SMAS flap rhytidectomy." Arch Facial Plast Surg 13(2): 108-108.
Facelift closure
Unilateral facial paralysis can result in drooping of the eyebrow. This can be severe enough in some cases to cause obstruction of vision in that eye. To treat this visual obstruction and improve the symmetry of the eyebrows, a brow lift can be performed. The most common means of lifting the brow in facial paralysis are either a direct brow lift, where skin is removed just above the eyebrow, or an endoscopic brow lift, where the brow is elevated using an endoscope. Small incisions placed in the hair-bearing scalp.
One of the most critical issues faced by patients with facial paralysis is the health of their eye on the paralyzed side of their face. All patients with facial paralysis need an examination by an ophthalmologist to determine the health of their cornea (the transparent outer layer of the eye). Some patients continue to have corneal dryness or irritation of the eye due to impaired eye closure. In these cases, a low-profile platinum weight may be inserted underneath the muscle of the upper lid to help the upper eyelid close more effectively. The incision is tucked in the crease of the upper eyelid, and heals nearly invisibly.
Through the same incision used for an upper lid weight, a minimally-invasive “tuck” of the lower eyelid can be performed. Repositioning and support of the lower eyelid has been proven to improve corneal coverage and improve corneal health in patients with facial paralysis14. More severe cases of lower lid malposition may require a lateral canthoplasty, or other surgical techniques.
[14] Chepeha, D. B., et al. (2001). "Prospective evaluation of eyelid function with gold weight implant and lower eyelid shortening for facial paralysis." Archives of Otolaryngology–Head & Neck Surgery 127(3): 299-303.
Patients with long-standing facial paralysis also suffer from atrophy (wasting) of soft tissue in the face. This not only worsens facial asymmetry, but also facial volume loss can impair facial function. For example, volume loss in the cheek can worsen lower lid malposition. Volume loss in the lip can worsen the escape of liquids from the mouth during drinking. As a potential solution to this, fat may be harvested from the abdomen or thighs using sterile liposuction devices. The fat is sterilely rinsed, then injected into areas of the face that have experienced volume loss as a result of facial paralysis. Fat grafting can also have a rejuvenating effect on the skin, which may be helpful in some cases of chronic facial paralysis.
Hyaluronic acid (HA) fillers are medical devices that are FDA-approved for temporary volume augmentation of different areas of the face. Their use in the setting of facial paralysis is not FDA approved, and therefore is considered “off-label.” Additionally, the use of these products may be deemed cosmetic by commercial or government payers. Despite these limitations, hyaluronic acid fillers may have an important role in the treatment of facial paralysis. Research has shown the injection of HA fillers into the lips improves speech, oral competence, and increases the strength of lip closure15. In addition to use in the lip, HA fillers may improve symmetry of the cheeks and other areas of the face.
[15] Starmer, H., et al. (2015). "Quantifying Labial Strength and Function in Facial Paralysis: Effect of Targeted Lip Injection Augmentation." JAMA Facial Plast Surg 17(4): 274-278.
FAQs
How do you treat chronic facial paralysis? ›
The most time-tested treatment for facial paralysis involves a facelift on the paralyzed side of the face, combined with a soft tissue from the leg that is used to hold up the corner of the mouth. In this procedure, tissue from the leg (fascia) is removed from the thigh through a surgical incision.
What is melkersson Rosenthal syndrome? ›What is Melkersson-Rosenthal syndrome? Melkersson-Rosenthal syndrome is a rare neurological disorder characterized by recurring facial paralysis, swelling of the face and lips (usually upper lip), and the development of folds and furrows in the tongue.
What causes permanent facial paralysis? ›Facial paralysis is almost always caused by: Damage or swelling of the facial nerve, which carries signals from the brain to the muscles of the face. Damage to the area of the brain that sends signals to the muscles of the face.
What is the overall recovery rate for idiopathic facial nerve paralysis? ›Approximately 80–90% of patients with Bell palsy recover without noticeable disfigurement within 6 weeks to 3 months. Use of the Sunnybrook grading scale for facial nerve function at 1 month has been suggested as a means of predicting probability of recovery.
Can facial paralysis be permanent? ›Paralysis of the face may be temporary or permanent. The facial plastic surgery team determines the best treatment based on how long the paralysis has been present, the cause and whether it is a complete paralysis, or an incomplete (or partial) paralysis.
Can facial paralysis be cured after years? ›Bell's palsy is not considered permanent, but in rare cases, it does not disappear. Currently, there is no known cure for Bell's palsy; however, recovery usually begins 2 weeks to 6 months from the onset of the symptoms.
What is Guillain Barre syndrome of face? ›Guillain–Barré syndrome is characterized by progressive motor weakness, sensory changes, dysautonomia, and areflexia. Cranial nerve palsies are frequent in Guillain–Barré syndrome. Among cranial nerve palsies in Guillain–Barré syndrome, facial nerve palsy is the most common affecting around half of the cases.
What is face Synkinesis? ›Facial synkinesis refers to involuntary and undesirable facial movements (aka “simultaneous movement”) associated with voluntary facial movements. An example is when one eye closes whenever a patient smiles. Synkinesis often develops in patients who have had Bell's palsy.
What is Miescher's cheilitis symptoms? ›Miescher's cheilitis consists in an inflammatory disorder with non-infectious and non-necrotic granulomas and it appears as a painless enlargement of the lips, with or without facial edema, producing both aesthetic and functional deformities.
What autoimmune disease causes facial paralysis? ›Bell's palsy may be an autoimmune demyelinating cranial neuritis, and in most cases, it is a mononeuritic variant of Guillain-Barré syndrome, a neurologic disorder with recognised cell-mediated immunity against peripheral nerve myelin antigens.
How do you know if facial nerve damage is permanent? ›
Symptoms of Permanent Facial Paralysis
Inability to move one or both sides of the face. Reduced tearing. Facial drooping and/or weakness. Slurred speech.
To the best of our knowledge, for the first time, vitamin C deficiency has been reported as a cause or triggering/risk factor for Bell's palsy and at the same time immune-inflammation triggered in BP also may lead to vitamin C deficiency as existing vitamin C in the body starts scavenging free radicals to prevent ...
Is facial paralysis a disability? ›If you are suffering from Bell's palsy, you may qualify for long term disability benefits to help you financially while you recover from your severe medical condition.
Can surgery fix facial paralysis? ›Surgery to Correct Facial Paralysis
Facial reanimation microsurgery -- sometimes referred to as "smile surgery" -- can restore your ability to smile spontaneously after a damaged facial nerve has caused facial paralysis. It can take two forms: muscle transfer or nerve transfer.
Electromyogram. An electromyogram measures the electrical impulses transmitted along nerves and muscle tissue. This test helps doctors evaluate weakness or paralysis in the facial muscles or nerves.
Can brain damage cause facial paralysis? ›showed that 28.6% of cases had simple brain contusions or subdural haematomas without a temporal bone fracture suggesting that high levels of shock injury can suffice in causing delayed facial nerve paralysis [9].
Can damaged facial nerves regenerate? ›Like any motoneurons of the peripheral nervous system, injured facial nerves in adults can regenerate.
Is facial paralysis a neurological disorder? ›Bell's palsy is a neurological disorder that causes paralysis or weakness on one side of the face. One of the nerves that controls muscles in your face becomes injured or stops working properly. Symptoms include: Sudden weakness or paralysis on one side of your face.
How can I restore my face muscles? ›Lip Movements.
Move your lips in different directions. Move your mouth from side to side, up and down, smiling, and in a “kissing pout.” These movements will help your facial muscles regain strength, and because they are natural movements, they can help to promote reactions to the brain.
The most common bacterial trigger for GBS and MFS is Campylobacter jejuni which can cause abdominal pain and diarrhea. Viruses that may cause MFS and GBS include HIV infection, Epstein-Barr (mononucleosis), and Zika virus.
What is frozen face syndrome? ›
Weakness or paralysis of the facial muscles is one of the most common features of Moebius syndrome. Affected individuals lack facial expressions; they cannot smile, frown, or raise their eyebrows. The muscle weakness also causes problems with feeding that become apparent in early infancy.
Does sarcoidosis cause facial paralysis? ›Facial palsy/plegia also represents a neurological manifestation of “Heerfordt's syndrome” (HS), an acute subtype of sarcoidosis seen in 0.3–1.2% of the cases of sarcoidosis [37]. HS is characterized by facial palsy, parotid gland enlargement, and uveitis associated with low-grade fever.
What is transient facial paralysis? ›Abstract. Bell's palsy is the sudden onset of unilateral transient paralysis of facial muscles resulting from dysfunction of the seventh cranial nerve.
What is House Brackmann for facial nerve? ›The House-Brackmann Facial Nerve Grading System is widely used to characterize the degree of facial paralysis. In this scale, grade I is assigned to normal function, and grade VI represents complete paralysis. Intermediate grades vary according to function at rest and with effort.
What is the bell's phenomenon? ›Bell's phenomenon is protective reflex in which the globe is turned upwards and slightly outwards during the eyelid closure to avoid corneal exposure.
What is glandular cheilitis? ›Cheilitis glandularis (CG) is a rare inflammatory condition that predominantly affects the minor salivary glands and surrounding tissues of the lips. It affects adults (over 40 years old) to a greater extent than young people and almost exclusively white individuals.
What is cheilitis granulomatosa syndrome? ›Cheilitis granulomatosa (CG) is a rare granulomatous disorder characterized by a recurrent firm swelling of one or both lips. This is called the cheilitis granulomatosa of Miescher (CGM) when it occurs in isolation.
What is cheilitis granulomatosa? ›Cheilitis granulomatosa is a rare, persistent, painless, idiopathic chronic swelling of the lip.
What causes Ramsay Hunt syndrome? ›The varicella-zoster virus that causes Ramsay Hunt syndrome is the same virus that causes chickenpox and shingles. In people with this syndrome, the virus is believed to infect the facial nerve near the inner ear. This leads to irritation and swelling of the nerve. The condition mainly affects adults.
Can Sjogren's cause facial paralysis? ›Moreover, bilateral peripheral facial paralysis associated with SS has been described only in 3 patients in the literature and the first case was described by Henrik Sjogren himself in 1935. We report a 59-year-old female with bilateral peripheral facial paralysis associated with Sjogren's syndrome.
How do you get Ramsay Hunt syndrome? ›
Ramsay Hunt syndrome occurs in people who've had chickenpox. Once you recover from chickenpox, the virus stays in your body — sometimes reactivating in later years to cause shingles, a painful rash with fluid-filled blisters.
Can MRI detect facial nerve damage? ›3.2. MRI. When using CT to evaluate the facial nerve, pathology often can only be inferred by visualization of erosion or destruction of the adjacent bony facial nerve canal. In contrast, MRI visualizes soft tissues well and so is better suited for evaluating soft tissue facial nerve abnormalities.
What are the neurological disorders of the face? ›Common facial nerve disorders include; Bell's palsy, Lyme disease, stroke, parotid/ear/skull base tumors, trauma to the nerve, viral infections, and congenital anomalies.
What can be mistaken for Bell's palsy? ›Conditions that may mimic Bell's palsy include CNS neoplasms, stroke, HIV infection, multiple sclerosis, Guillain-Barré syndrome, Ramsay-Hunt syndrome, Melkersson-Rosenthal syndrome, Lyme disease, otitis media, cholesteatoma, sarcoidosis, trauma to the facial nerve, autoimmune diseases such as Sjogren's syndrome, and ...
What is facial nerve paralysis common with? ›Idiopathic/Bell Palsy (70%)
Most commonly, the cause for facial nerve palsy remains unknown and has the name 'Bell palsy. ' Bell palsy has an incidence of 10 to 40 per 100000. [2] It is a diagnosis of exclusion. It usually presents as a lower motor neuron lesion with total unilateral palsy.
Facial Paralysis
While facial drooping is often a sign of other disorders such as Bell's palsy, Lyme disease, or even stroke, it may be an early sign of MS. No matter what is causing the facial paralysis, you should get immediate medical help to address the problem.
Facial nerve paralysis is most often seen with intratemporal tumors that involve the labyrinthine segment. Extratemporal parotid tumors may also present with facial paralysis, especially if they are malignant.
Can you drive with facial paralysis? ›The patient with unilateral peripheral facial paralysis should rest the first days that are associated with significant anxiety and worry, and should not drive. He cannot be led when the palpebral cleft is broad and the eye cannot be closed. The temporal occlusion of the affected eye is disabling for driving.
Can stress cause face paralysis? ›One response to severe stress is that the body's immune system is weakened. The weaker the body's immune system, the less functional the body's systems are. A weakened immunity can lead to parts of the body not functioning correctly, such as with Bell's Palsy.
Who treats facial paralysis? ›You'll likely start by seeing your family doctor or other health care provider. However, in some cases when you call to set up an appointment, you may be referred immediately to a doctor who specializes in the nervous system (neurologist).
Can a pinched nerve cause facial paralysis? ›
A pinched facial nerve causes this paralysis, or palsy. People with this type of facial nerve palsy develop a droopy appearance on one — or sometimes both — sides of the face. The condition isn't serious and often resolves in a few months without treatment.
How long does it take for facial nerves to heal? ›Many people recover from sudden facial nerve paralysis without medical treatment, though full recovery may take as long as a year.
What are the symptoms of a damaged cranial nerve? ›Individuals with a cranial nerve disorder may suffer from symptoms that include intense pain, vertigo, hearing loss, weakness or paralysis. These disorders can also affect smell, taste, facial expression, speech, swallowing, and muscles of the neck.
Can facial paralysis be treated? ›Most people with Bell's palsy recover fully — with or without treatment. There's no one-size-fits-all treatment for Bell's palsy. But your health care provider may suggest medications or physical therapy to help speed your recovery. Surgery is rarely an option for Bell's palsy.
What is a long term facial paralysis? ›Long-term sequelae of facial nerve palsy may be persisting weakness, contractures, facial spasms, synkinesis, decreased tearing, crocodile tears, or psychosocial effects [2]. In patients who recover without treatment, major improvement occurs within 3 weeks.
What is the best vitamin for facial paralysis? ›Vitamin B12 injections have been shown to be beneficial for people with Bell's palsy. Vitamin B12 deficiency can cause nerve degeneration, and both oral and injected vitamin B12 have been used to treat many types of nerve disorders.
How do you treat permanent paralysis? ›Currently, no cure for paralysis exists. However, depending on the cause and type of the issue, some people experience partial or complete recovery. Temporary paralysis, such as that caused by Bell's palsy or stroke, may resolve on its own without medical treatment.
Can you fix nerve damage in face? ›When facial paralysis is due to facial nerve damage, several surgical options are available. If the denervation is due to neurotmesis or a complete nerve transection, early nerve coaptation is the best option. If coaptation without tension is not possible, a cable graft interposition can be used.
Can facial nerve damage repair itself? ›Minor and superficial nerve injuries will often heal themselves. Examination, neurophysiology and clinical imaging will determine whether the injured nerve needs repair, and if so, the options for surgical reconstruction.
What syndromes have facial paralysis? ›Moebius syndrome is a type of congenital facial paralysis or palsy. The condition usually affects both sides of the face. While researchers have not identified the cause(s) of Moebius syndrome, studies suggest a combination of genetic and environmental risk factors.
Can B12 repair nerve damage? ›
In many cases, supplementing with vitamin B-12 can reduce the pain associated with neuropathy. More rarely, it can help repair the myelin sheath, depending on the cause of the neuropathy. However, B-12's ability to speed up tissue regeneration and improve nerve function can be helpful for some.
What deficiency causes paralysis? ›Combined deficiency of vitamins E and C causes paralysis and death in guinea pigs.