What Is Facial Paralysis?

The effects of facial paralysis can be significant. Here’s what you need to know.

Facial paralysis is a devastating condition that can rob people of their sense of self. Patients often tell me how their facial paralysis has taken away their identity, their ability to speak, eat, smile and convey emotions.

The following are some of the most common questions patients ask me about facial paralysis.

1. What causes facial paralysis?

Facial paralysis is most commonly caused by Bell’s palsy, which is inflammation of the facial nerve due to a virus. Other common causes of facial paralysis include a tumor along the path of the facial nerve or trauma to the nerve, either from surgery or a blunt/penetrating injury to the head or face.

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2. What is the difference between acute and chronic facial paralysis?

Acute facial paralysis is any facial paralysis that has lasted for less than 12 months. Chronic facial paralysis is paralysis that has lasted longer than 12-18 months without improvement.

3. What are the effects of facial paralysis?

Facial paralysis can have functional, behavioral and psychological effects. The functional effects are the one we can see with our eyes as observers — these include facial asymmetry; difficulty closing your eye; excessive tearing; difficulty breathing through your nose on the affected side; inability to smile; difficulty retaining food in your mouth when eating or drinking; and, sometimes, difficulty with speech.

4. What are the treatment options for facial paralysis of the upper face/eye?

Patients with facial paralysis of the upper face typically have a low-lying eyebrow, also called brow ptosis. This can be treated with a brow lift. Depending on the severity, different approaches can be performed. Patients may also have difficulty closing the eye, which leads to dryness and possible exposure injury. To prevent this, we often place an eyelid weight under the skin and also perform a lower eyelid shortening procedure, called a tarsal strip, to help with closure.

5. What are the treatment options for facial paralysis of the midface?

Most patients with facial paralysis of the midface complain about difficulty breathing and facial asymmetry. Nasal breathing can be improved with several options but typically involves a surgery to repair the nasal valve, which often becomes obstructed. The midface can also be lifted through an endoscopic or open approach to improve symmetry.

6. What are the treatment options for facial paralysis of the lower face?

The goal for repair of lower facial paralysis is to improve the smile. Depending on how long you have had facial paralysis, there are several treatment options:

  • For patients with complete facial paralysis for less than one year, options include using a nerve graft from somewhere else in the body or a nerve transfer from another nerve nearby, such as the nerve to masseter muscle or the hypoglossal nerve. This requires you to bite down to initiate a smile or move your tongue.
  • If your paralysis is complete and has lasted more than 12-18 months, then you may benefit from a tendon transfer from the temporalis muscle or from a type of surgical procedure called a gracilis free flap, which requires taking a small muscle from your thigh and transplanting it into your face with an artery, vein and nerve. Gracilis free flap surgery is a complex procedure that requires several days in the hospital but offers the benefit of healthy vascularized tissue and allows you to have spontaneous movement.

7. Is surgery for facial paralysis covered by insurance?

Most health insurers will cover surgical treatment for facial paralysis. If you have questions about your coverage, please check with your provider before starting therapy.

8. What is Bell’s palsy?

Bell’s palsy is sudden-onset, acute facial paralysis, due to a viral illness. Its full effects can be observed within 48 hours. The paralysis usually affects one side of your face, but it’s possible that both sides can be affected. Other symptoms that may appear include:

  • Eye problems – an eyelid may become paralyzed, making it hard to blink.
  • Oral problems – the tongue may have an altered sense of taste, and saliva production may be affected. A corner of the mouth may remain open as well, which can cause drooling.
  • Pain – you may feel pain develop in front of or behind the ear of the affected side.

9. How long does Bell’s palsy last?

Typically, facial paralysis from Bell’s palsy improves within a few weeks to months. If you have been diagnosed with Bell’s palsy but have not recovered any facial function after six months, you should be evaluated to make sure nothing else is causing the paralysis.

10. What is the treatment for Bell’s palsy?

Immediate treatment for Bell’s palsy includes oral steroids and antiviral medications. If symptoms persist, some patients may also benefit from physical or occupational therapy and additional treatment by a trained specialist in facial reanimation.

11. Can Bell’s palsy come back?

In very few cases, patients will develop recurrent facial paralysis, but that is very rare.

12. What is facial synkinesis?

Facial synkinesis is abnormal movement of the face. About 10% of patients with Bell’s palsy will develop some type of synkinesis. Examples include uncontrolled eye closure with mouth movements such as smiling or eating. It may also involve tightness of the neck muscle, also known as the platysma, with smiling.

13. How is synkinesis treated?

One way to treat synkinesis is with chemodenervation, which is a process that involves using botulinum toxin, or Botox, to turn off abnormal muscle activity. The effect of this treatment lasts about three months and has a high percentage of success in the right hands. Physical therapy with a trained facial retraining therapist is also an excellent option for patients with synkinesis.

In rare cases, a type of surgery called selective neurolysis, may be performed to treat synkinesis.

14. Does synkinesis ever go away?

Unfortunately, synkinesis does not go away completely; however, if you see a trained specialist, you may be able to reduce its effects so that they are less distracting to you.

15. Is botulinum toxin or facial retraining for synkinesis covered by insurance?

Most health insurers will cover treatment for synkinesis, but you should check with your provider before starting therapy.

16. Are there side effects to using botulinum toxin?

The main side effect to using botulinum toxin for synkinesis is that you may receive too much and then have difficulty closing your eye or smiling. Luckily, botulinum toxin wears off after a few months, and the side effects are short-lived. However, it is still important to seek treatment from a trained expert in managing facial synkinesis.

by Amit Kochhar, MD

Amit Kochhar, MD, is a board-certified otolaryngologist who specializes in facial plastic and reconstructive surgery at Keck Medicine of USC and is a clinical assistant professor of otolaryngology – head and neck surgery at the Keck School of Medicine of USC.

Do you have facial paralysis? The expert otolaryngologists at the USC Facial Nerve Center can help. If you are in the Los Angeles area, make an appointment or call (800) USC-CARE (800-872-2273).