Facial paralysis involves either partial or complete weakness of the muscles of the face. This can affect all age groups for a large variety of reasons. At times the paralysis will only affect one portion of the face, while others have one entire half of the face affected, and rarely both sides can be paralyzed. This can be a very challenging condition for many people because it impacts facial movement, appearance, emotional expression, social interactions, and critical functions like blinking, breathing through the nose, speaking, and eating. Whenever facial paralysis is present, a very careful search for the cause should be undertaken because the treatment recommendations may vary significantly based on the cause of the paralysis. Treatment of facial paralysis is complex and individualized requiring a thorough discussion between the individual and treating physician to compare the risks and benefits of each treatment option in light of the individual’s goals and quality of life. See one of our patient stories.
Facial Muscles and Nerve Branches: Pathway of facial nerve to the muscles that move the face
The facial nerve is the seventh cranial nerve (CN VII) which means the nerve starts in the brain. From the brain it travels along with the hearing nerve through an opening in the skull then passes through the ear beneath the eardrum and through the mastoid bone behind the ear. The nerve leaves the skull through an opening behind and below the ear and passes through the parotid gland (saliva gland) on the side of the face. This nerve branches into multiple divisions that connect with the muscles that move the face beneath the skin. There are over 40 muscles in the face that work together to create the many varied facial expressions that humans are capable of expressing. For the face to move normally there has to be an intact connection between the brain, nerve, and muscle much like a table lamp will only work if plugged into a working outlet with intact power cord and functional light bulb. A disruption anywhere along this connection may lead to facial paralysis.
In addition to carrying the signal for the facial muscles to move, the facial nerve also carries the signal to the lacrimal gland near the eye to produce tears. The nerve also connects the taste buds from the front portion of the tongue to the brain and some of the sense of feeling around the ear.
There are a wide variety of causes for facial paralysis that can be broadly categorized into congenital (present at birth), acute (occurring over a short period of time), or chronic (occurring over a longer period of time).
Congenital paralysis is present at birth and may affect one or both sides. Some cases are occasionally related to trauma during the birth process and may improve with time, while most others are associated with other syndromes or developmental abnormalities of the facial nerve or muscle that tend to cause permanent paralysis.
Acute facial paralysis occurs over a short period of time, usually less than three days. The most common reason for this is Bell’s palsy, but there numerous other causes including stroke, infection, autoimmune diseases, neurologic disorders, tumors, surgery, and trauma. This type of facial paralysis tends to be most severe shortly after it begins and may show some improvement with time.
Chronic facial paralysis occurs over a longer period of time and typically the paralysis worsens with time. This may involve just a portion of the face or one entire half of the face. This type of paralysis is most worrisome for a growth or tumor pushing on or extending into the facial nerve at some point along the course of the nerve. The most common tumor type is a benign growth that occurs inside the skull is called a vestibular schwannoma, but other brain tumors or nerve growths can cause the same type of paralysis. Also of concern are growths within the parotid (saliva) gland in the side of the face, or certain skin cancers that spread from the skin along the nerve. Facial paralysis related to tumors does not typically improve until the tumor is treated. Once the tumor is removed the face may regain function in some cases while in others the paralysis is permanent.
Bell’s palsy is the most common cause of sudden onset facial paralysis. The paralysis comes on quickly, over a period of less than three days, and usually affects one entire side of the face. Some people with Bell’s palsy are able to move their facial muscles a little bit while others cannot move their muscles at all. With the paralysis there may be associated pain in the ear, sensitivity to loud noises, changes in taste, numbness on the same side of the face, or changes in tear production. In addition to lack of facial expression, people with Bell’s palsy can also have difficulty with speech, eating, eye closure and breathing through their nose.
This can be a very shocking experience, and many people initially think they are having a stroke. People suffering from acute facial paralysis should seek medical attention immediately, to identify the cause of the paralysis and start treatment. The exact cause of paralysis in Bell’s palsy is not known, but it is thought to be related to swelling of the facial nerve as it passes through a very narrow opening in the bone on its way from the brain to the facial muscles; some theories suggest a viral or autoimmune cause. The most effective treatment for Bell’s palsy is a course of steroids to counteract the swelling and inflammation around the nerve. There may also be a benefit from antiviral medication in addition to steroids. It is very important that people who cannot fully close their eye start eye lubrication treatment to prevent dryness, inflammation, or ulceration from developing.
For most people the swelling around the nerve is temporary and facial movement begins to return within a few weeks of paralysis. Some people do not see return of function begin for several months. The sooner recovery begins, the more complete recovery will be, but full recovery can take up to 12 months. Fortunately, a large percentage of people will return to normal or near normal facial function following Bell’s palsy, but up to 25 to 30% of people will have incomplete recovery.
Incomplete recovery can take many forms. For some this means that a portion of the face does not move as much as the other side. Others will feel their face tighten, often in the cheek, around the mouth, or in the neck. Some develop synkinesis which is dis-coordinated movement of different regions of the face such as eye closure with mouth movement. Some people develop a combination of these issues. The best way to minimize these complications is to prevent them from developing in the first place. Early treatment with steroids and antiviral therapy can help improve the odds of normal facial function and minimize the development of facial tightness and synkinesis. Once facial function has begun to recover, a personalized plan of facial massage and facial retraining may also improve outcomes for certain individuals. If facial tightness or synkinesis has developed, targeted chemodenervation with Botox® injections can be helpful to restore facial balance and minimize these symptoms. Some people may ultimately require surgical intervention if their face does not recover adequately. There are many surgical procedures utilized and often times a combination of procedures is recommended to achieve the most balanced results. These are discussed in more detail below but include procedures to restore eye brow symmetry, assist with eye closure, improve nasal breathing, and improve smile production and lip movement.e
Identifying the cause of the facial paralysis is critical to determine the best course of treatment. In some cases the treatment may be to allow the facial function to improve on its own. In others, treatment may involve medical therapy, physical therapy, minimally-invasive facial injections, or even surgery. Since every individual is affected differently by facial paralysis, the treatment must be individualized to the individual and the circumstance of paralysis.
Because facial paralysis affects so many aspects of an individual’s life, the goals of treatment must address each of these aspects. Ultimately the goal of treatment is to restore the face to as much symmetry and function as possible to allow the patient to live a normal life without physical or social concerns related to their facial paralysis.
For certain causes of facial paralysis, early medical treatment may improve recovery. These treatments include medications such as antibiotics, antivirals, and steroids. Not all causes of facial paralysis benefit from medical treatment, however, and this is why it is important to undergo evaluation as soon as the paralysis develops.
There are two main types of in office injections used to help people with facial paralysis; these are botulinum toxin (Botox®) and injectable filler. Both work in different ways and may be used together to help optimize facial function.
Botox® works by temporarily weakening the muscle it is injected into and has been used for years in facial paralysis. In this treatment, very small doses are injected into muscles in the face primarily to help decrease excess muscle tightness or synkinesis (dis-coordinated muscle movement) than can result from incomplete recovery of facial paralysis. By selectively weakening muscles that are over active or working out of sync with the rest of the face, the function and balance of the face can be improved. This can significantly help decrease eye closure that occurs with smiling, chin dimpling, neck tightness, brow furrowing, or cheek tightness. This is often combined with a facial retraining regimen for optimal results. Additionally, Botox® can be used on the opposite side of the face to partially weaken muscles in the forehead and lower lip to improve overall facial symmetry. The injections are easily performed in the office with only minor discomfort. The results take one to two weeks to reach full effect and are temporary as the medication usually wears off after three to four months. Repeat treatments are very effective and safe for years if needed. Determining the best dose and location of injections requires a coordinated approach between the patient and surgeon, but most patients are extremely happy with the improvement seen from this treatment. Some patients who see initial benefit from Botox® injections, but lose this benefit over time may respond well to a different type of botulinum toxin injection. For some seeking a more permanent solution a super-selective neurolysis may be a surgical option to carefully target specific small facial nerve branches to cut in order to partially weaken the involved muscle in a long-term fashion.
Injectable filler comes in many forms and these are described in more detail in the Filler section. Filler injection helps restore volume to various parts of the face and have been used for years in both cosmetic and reconstructive applications. Some patients with facial paralysis have a lot of difficulty with lip weakness and have to alter their eating habits to avoid spilling liquids out of the corner of their mouth. Lip strength can be measured easily by speech and language pathologists and if found to be weak on the affected side, a small amount of filler injected into the lips around the corner of the mouth can significantly improve these symptoms. The goal of this treatment is not to make the lips look bigger, but simply to restore some volume and provide more of a barrier to liquids escaping.
Facial filler injections can also be used to help improve overall facial symmetry following facial paralysis. The exact locations for filler use vary based on the individual, but may help blunt the nasolabial fold around the upper lip and mouth that may be deeper on one side than the other or can restore volume in the cheek and help support the lower eyelid that may be drooping after paralysis.
Facial filler treatment is easily accomplished in the office with topical or local anesthesia and minimal discomfort. The effects of the injections are immediate, but most fillers are temporary with results lasting between six months to two to three years depending on the type of filler used and the location. There may be some temporary swelling or bruising following filler injection, and other rare side effects are possible, but overall, filler injection is quite safe and minimally invasive. Depending on the specific treatment, some injections may not be covered by all insurance companies.
A specialized form of neuromuscular retraining known as facial retraining has been developed by dedicated physical therapists to help with facial function in patients who are recovering from paralysis. This is an individualized form of therapy that requires regular practice and participation by the individual. Therapy may involve a combination of facial massage and relaxation techniques to counteract facial tightness, along with targeted facial exercises to improve movement and symmetry. Often times biofeedback utilizing mirror training or EMG electrodes applied to the skin is used to allow the individual to monitor and adjust their facial movements. Normal facial movements are relatively small and happen quickly; they rarely involve contracting the muscle as hard as possible. Retraining focuses on optimizing these movements and striving toward symmetry of movement on both sides of the face.
Facial paralysis affects the ability to move the lips and cheeks which have an impact on an individual’s ability to speak and eat. Assessment by a speech and language pathologist can identify specific difficulties for each person and may offer compensation strategies to help with these important functions. Assessments can also be helpful to follow an individual after treatment or during recovery to track improvement.
For some patients or causes of facial paralysis, medical treatment and therapy may not provide enough benefit and surgical treatment may be recommended. To better optimize facial symmetry and function, surgical treatment is often broken down into various zones of the face (forehead/eyebrow, eye, nose, mouth, neck) and categorized by the type of reconstruction either static or dynamic. Static reconstruction refers to interventions that do not recreate movement, but simply reposition features of the face for better symmetry and function, while dynamic reconstruction restores movement of the facial landmark. The optimal goal in treating facial paralysis is to restore dynamic function to the entire face, but for certain portions of the face or types of paralysis this can be very difficult and static reconstruction may be the best available option.
Left sided weakness from facial paralysis
After masseteric nerve transfer and fascia lata suspension
For certain types of facial nerve injuries, the best option for reconstruction is to directly repair the nerve. If the facial nerve or one of its branches is cut either due to trauma or surgery, the recommended treatment may involve finding the cut ends of the nerve and re-connecting them with microsutures as soon as possible. For injuries to small branches of the nerve closer to the center of the face, this type of repair may not be possible or beneficial as facial function following these injuries may return spontaneously. Injuries involving larger nerve branches closer to the ear, however, may benefit from surgical repair and the best results are seen when this is done as soon as possible following the injury. At times the ends of the nerve will not reach one another and a nerve graft may be needed to bridge the gap from one end of the nerve to the other. This may be the case when a portion of the facial nerve has to be removed along with a tumor. Nerve grafts can come from many locations, but two of the most popular are the great auricular nerve in the neck that gives sensation to the earlobe, or the sural nerve in the lower leg that gives sensation to the heel. Direct nerve repair, or repair with a nerve graft does not produce facial function that is as good as it was before the nerve injury, but this can restore spontaneous movement and function. Results of a nerve repair or graft are not immediate as the nerve has to repair itself and grow from the site of the injury to the facial muscles. This may take several months up to one year for full recovery to be seen. Some patients following nerve repair or grafting develop dis-coordinated movements of the face known as synkinesis. This can cause different parts of the face to move together at the same time, such as the eye closing during a smile. These symptoms can be improved with targeted facial retraining or Botox® therapy as described previously.
Masseter Nerve Transfer: Depiction of surgical connection between masseteric nerve and a branch of the facial nerve
In some cases the facial nerve cannot be repaired directly because the portion of the nerve between the brain and the site of injury is not functional even though the nerve between the site of injury and the muscles is viable. In these cases a different cranial nerve can be transferred and connected to the functional side of the facial nerve to provide a new power source for the muscles. This is similar to taking a table lamp whose power cord had been severed and splicing into a cord plugged into a different outlet for power supply. This type of procedure is only possible relatively soon after the paralysis occurred because after enough time has passed, the connection between the nerve and muscle becomes replaced with scar tissue and will not function well even with a different power source.
There are three main nerves that are commonly used for nerve transfer procedures. The first is using select branches of the facial nerve on the opposite side of the face though what is known as a cross facial nerve graft. In this procedure, targeted branches of the facial nerve on the functional side of the face are cut and connected to a sural nerve graft from the lower leg. This graft is passed under the skin to the paralyzed side of the face (often within the upper lip) and connected to the injured nerve. Once the nerve has grown through the graft across the face, when the functional side of the face moves the signal will be sent to the paralyzed side to trigger movement at the same time. This procedure offers a nice advantage of restoring truly spontaneous movement such that when the functional side smiles the paralyzed side will also smile without additional effort. More than one nerve graft can be used to isolate specific facial movements, for example one graft may be placed to the branch to help with eye closure and another to help with smile. The main disadvantage to this procedure is the relatively short time window available following the paralysis that it may be effective. The exact cut off time frame is not completely known, but the best results are seen when the procedure is done within the first few months of paralysis; surgery done after 6 months tends to be much less successful. Also, because of the total distance the nerve has to grow through the graft to recover, there may be somewhat less movement seen with this nerve compared to other nerve transfer options.
When the cross facial nerve graft is not a good option, another cranial nerve may be selected with the hypoglossal nerve to the tongue (CN XII) and the masseteric branch of the trigeminal nerve (CN V3) as the two most popular options. There is also a time limitation for these procedures with best results seen the earlier the nerve is transferred, but good results have been seen up to two years after the paralysis. The hypoglossal nerve provides motion to half of the tongue and has been used for years to help re-animate the face. The procedure has changed throughout the years in an attempt to minimize tongue weakness following the procedure. This procedure typically involves an incision placed in front of the ear extending into the upper neck. The hypoglossal nerve is located below the jaw line in the neck and typically only 30 to 40% of the nerve is cut leaving the rest of the nerve intact to limit tongue weakness. This nerve is then connected to the facial nerve in one of two ways. If the goal is to animate only a specific portion of the face, then a nerve graft is connected between the hypoglossal and the facial nerve branch target. Another option is to connect the entire facial nerve to the hypoglossal by removing it from the mastoid bone behind the ear. Once the nerve has healed the face typically has improved muscular tone that provides better symmetry at rest, and movement can be seen of the facial muscles when the tongue moves. This requires a period of re-training to determine the best method of tongue movement to achieve the desired facial movement. The movement may be stronger than that seen with a cross facial nerve graft, but is not spontaneous. Even with the newer hypoglossal transfer procedures there is a risk for weakness to the tongue that may affect speech and swallowing. When the entire facial nerve is connected to the hypoglossal nerve, there may also be more synkinesis or movement of the entire half of the face when the tongue moves rather than movement of only the desired portion of the face.
Right sided weakness from facial paralysis
After masseteric nerve transfer
Due to some of these drawbacks, recently surgeons have become interested in transferring the masseteric nerve for very targeted facial re-animation. The masseter is one muscle that helps close the jaw with chewing and runs just in front of the ear from the cheekbone to the angle of the jaw. This procedure is done with a limited incision in front of the ear and no need to extend this into the upper neck. The masseteric nerve is found within the muscle and the strongest branch is selected for transfer. Typically there is a second or third branch that can remain in place to limit weakness to the muscle after transfer. This nerve branch can then be connected directly to the desired branch of the facial nerve. Often this is directed to the branch that produces a smile, but it can also be connected to a branch that helps with eye closure, or a larger branch that performs both functions. There is usually no need for a nerve graft in this procedure. Once the nerve has healed, clenching the jaw will trigger movement in the portion of the face that the nerve is connected to. Like the hypoglossal transfer this is not a totally spontaneous movement and requires re-training and practice. However, some patients are able to trigger a smile from the masseter nerve in a much more natural way than with the hypoglossal nerve. If the masseteric nerve is connected to the main facial nerve, the same problems with synkinesis may develop, but often this nerve is transferred to a select branch of the facial nerve so it triggers only the movement that is desired.
A lot of attention is devoted to restoring function and symmetry of the mouth in facial paralysis, particularly in re-creating a smile. Our smile is a critical component of our identity that helps display emotions to others. Smiles are contagious; a smile from one person naturally triggers reflexive smiles from those around that person. A smile that is not met with a smile in return can be very disheartening and can lead to discouragement and avoidance of smiling overall. For these reasons, every effort is made to restore a dynamic smile whenever possible. Static suspension of the mouth can be done much like nasal suspension with a piece of fascia from the leg used to hold up the corner of the mouth. This can improve the symmetry of the mouth at rest, but doesn’t help create a smile. This can be done as a temporary procedure when nerve function is expected to return, as a definitive procedure when a person has significant asymmetry but may not be healthy enough to undergo a more involved procedure, or as a way to “fine tune” the position of the mouth in a person with mouth asymmetry but otherwise intact motion.
Temporalis Tendon Transfer: Depiction of surgical transfer of temporalis tendon to dynamically lift the corner of the mouth
The nerve transfer procedures such as cross facial nerve graft and masseteric nerve transfer are often directed toward reanimating the smile. This way the entire nerve transfer is dedicated to smile production to provide the most amount of power possible. If the paralysis has been present for more than two years, however, a nerve transfer procedure is less likely to be effective and a new muscle must be used to provide motion for the smile. The most common procedures to accomplish this include the temporalis tendon transfer (T3) and free muscle transfer with the gracilis muscle.
The temporalis is a strong muscle attached to the side of the skull with a tendon that passes under the cheek bone and attaches to a part of the jaw bone. This muscle assists with jaw closure along with several other muscles. The tendon of this muscle can be detached from the jaw bone and connected to the corner of the mouth either through an incision in the natural crease that runs along the upper lip or through an incision inside the mouth. Once this tendon is attached and healed in place, the corner of the mouth will elevate in a smile when the temporalis muscle contracts during jaw clench. Sometimes the tendon will not reach all the way to the corner of the mouth and a small piece of fascia (strong connective tissue) from the leg can be sewn in place to extend the tendon. The corner of the mouth is usually somewhat over-elevated compared to the opposite side at first, but this tends to relax with time. The procedure can improve the symmetry of the mouth at rest and help return smile motion to the paralyzed side. The muscle works immediately, but there is some re-training and practice involved to learn to create an even smile by clenching the jaw.
Gracilis Free Flap: Depiction of surgical gracilis muscle transfer to reanimate the smile, showing both innervation options of masseteric nerve and cross facial nerve graft. Blood vessels from the gracilis muscle are connected to blood vessels from the neck.
An alternative procedure involves transferring new muscle to the paralyzed side that is connected from the corner of the mouth to the cheek bone in the same direction of the natural facial muscles. The most popular muscle for this is the gracilis muscle which is located in the inner thigh. A small portion of this muscle is removed along with an artery and vein to provide blood flow and a nerve to provide power to the muscle. This is known as a free tissue transfer or “free flap.” On the paralyzed side of the face a facelift style incision from in front of the ear that extends into the upper neck is made and a tunnel is created that reaches to the corner of the mouth. The strip of muscle is then secured between the corner of the mouth and the cheek bone in a direction that matches the smile movement on the opposite side. The artery and vein of the gracilis muscle are then sewn together under the microscope to an artery and vein in the neck to provide blood flow to the muscle. The nerve to the gracilis muscle is also connected with microscopic sutures to an intact cranial nerve that will power the muscle. This procedure requires several months for the nerve to grow in and the muscle to begin moving, but the transferred muscle is quite strong and can produce a very strong smile.
There are two main options for nerve supply to the gracilis muscle. One involves using the facial nerve on the opposite side and requires two surgeries over all. In the first surgery one of the facial nerve branches on the non-paralyzed side that produces a smile is connected to a sural nerve graft from the lower leg. This graft is tunneled under the skin in the upper lip like the cross facial nerve graft described above. This nerve graft then slowly grows from the point of connection across the upper lip and usually takes nine to twelve months to reach the opposite side. Once the nerve graft has grown all the way across, the second stage of surgery is done that involves transferring the gracilis muscle to the face. At this stage the nerve to the gracilis is connected to the cross facial nerve graft. There is another waiting period for the nerve to grow the rest of the way into the gracilis muscle, but once this is complete a smile produced on the non-paralyzed side will spontaneously cause the gracilis muscle to contract and produce a smile on the paralyzed side.
The second option only requires one surgery where the nerve to the gracilis muscle is connected to the masseteric nerve on the paralyzed side. Once the nerve has grown in fully the smile created by the gracilis muscle is triggered by clenching the jaw. Much like the masseteric nerve transfer, this procedure requires a period of practice and learning how to activate the muscle. This smile is not as spontaneous as that produced by the two-stage cross facial nerve graft, but in some patients it can be done without much conscious thought. The smile produced by the masseteric nerve input tends to be a little stronger and more reliable than that of the cross facial nerve graft. For some patients the two nerve sources (cross facial nerve graft and masseteric nerve) are combined to both supply the gracilis muscle to gain the advantages of both procedures.
There are often many decisions to be made to select the best procedure to re-animate the smile. Deciding which procedure is best requires a thorough discussion between the patient and surgeon to compare the risks and benefits of each option in light of the patient’s goals and quality of life.
Treatment of the eyes is one of the most important components to treating facial paralysis. Facial movements are responsible for producing a blink that is critical for moisturizing and protecting the eyes to allow for clear vision. When eye closure is incomplete the surface of the eye may dry out which can lead to irritation, inflammation or ulcer development. In the most severe cases this can lead to blindness. For those people who cannot fully close their eyes, regular application of liquid artificial tears during the day plus a thicker ophthalmic ointment at night can help lubricate and protect the eye. When sleeping the eye may remain open, so for some people it is recommended to tape the eyelid closed at night or wear a moisture chamber to protect the surface of the eye.
Restoring a dynamic blink is the ultimate goal for reanimation of the eye. This can be accomplished via nerve grafts or nerve transfers for the appropriate scenario as described above. Several researchers are investigating methods to improve eye closure with muscle transfer, artificial muscle, or nerve stimulation, but these are not developed enough yet for clinical use. The two main components of incomplete eye closure for most people are: incomplete descent of the upper eyelid and weakness or drooping of the lower eyelid. Improving eyelid closure requires a careful assessment of which factors are involved in poor eye closure for each patient, and we often work with our colleagues in ophthalmology to fully assess eye health.
One common intervention to help the upper eyelid close involves placing a thin platinum weight under the skin in the upper eyelid. This does not create a blink, but can help the eyelid close along with the force of gravity. Eyelid weights come in various sizes and a trial can be done in the office to test various sizes to see which produces the best eye closure without weighing down the eyelid too much with the eye open. There are commercially available adhesive eyelid weights (Blinkeze) that can be custom ordered and worn taped to the eyelid for a period of time as a trial to determine the amount of benefit. The surgical procedure to implant the eyelid weight can easily be done under local anesthesia in the office. A small incision is made in the natural skin crease in the upper eyelid and the weight is secured beneath the skin with sutures. This weight can be removed at a later time if there is return of blink function or the weight is no longer needed. An additional procedure that can help with eye closure is partial suturing of the upper and lower eyelids together in the outer corner. This is known as a partial tarsorrhaphy. This can help support the lower eyelid somewhat and helps narrow the distance between the upper and lower lids. This can also be done under local anesthesia and reversed in the future if it is no longer needed.
At times the lower eyelid needs to be supported and held up in a better position. Ideally the lower eyelid and the small tear duct in the corner of the eye touch the eye ball to allow tears to drain into the nose. With paralysis, the lower eyelid can become droopy and sag away from the eye ball. Sometimes this affects the inner corner near the tear duct, sometimes it affects the outer corner more, and sometimes the whole lower eyelid is affected. There are several procedures that can be done to support the lower eyelid either in the inner corner, outer corner, or both. Collectively these procedures are referred to as canthoplasties and use various techniques to secure the eyelid into a better position with sutures to the bone or tendons around the eye socket.
Dynamic reanimation of forehead and eyebrow movement is unfortunately less successful than other regions of the face. The eyebrows are important in framing the eyes and movement of the forehead and eyebrows play a role in facial expression and non-verbal communication. In today’s society it is increasingly popular to treat the forehead and brow region with Botox® to reduce wrinkles in this location. This trend may be beneficial for those with paralyzed eyebrows since it is more socially acceptable to see faces with limited forehead motion. Even if dynamic forehead motion cannot be restored with nerve grafts or transfers as described above, eyebrow symmetry can be improved through static procedures. Following facial paralysis it is common to have drooping of the eyebrow on the affected side, this is known as brow ptosis. This can be effectively treated with a brow lift through a variety of techniques. The exact technique selected will be based on a variety of factors including extent of brow asymmetry, existing hair line and style, skin type and quality, patient age, and patient interests. A brow lift can be achieved endoscopically where all incisions are hidden within the hair and the brow is elevated and fixed into an improved position with small anchors to the bone. Alternatively an indirect brow lift involves an incision in the forehead in a natural skin crease or a direct brow lift with the incision just above the hair of the brow. While a brow lift will not return function of the forehead, it can help lift the droopy eyebrow to the same height as the opposite side so there is improved symmetry at rest.
Asymmetric brow from facial paralysis
After endoscopic brow lift
After direct brow lift
Even with a brow lift, the forehead and eyebrows will remain asymmetric during expression when the non-paralyzed eyebrow moves. This can be improved by weakening the muscles of the non-paralyzed eyebrow and forehead with Botox® injections. With this treatment there is limited movement of either side of the forehead so the brows appear more symmetric and motion on only one side does not draw attention in a social situation.
There are small muscles that normally hold the nostril open to allow airflow into the nose. When part of the face is paralyzed, these muscles do not open the nostril as well and the functional muscles on the opposite side may pull the nose towards the non-paralyzed side. This often combines to create trouble breathing through the nose on the paralyzed side. If there is any underlying deviation of the nasal septum this can make breathing through the nose even more difficult. The area just inside the nostril is referred to as the external nasal valve and this is commonly narrowed in facial paralysis.
There are several options available to address this problem and the treatment selected depends on the severity of the breathing issue and any underlying nasal asymmetries. Often a person will discover that using his or her hand to pull the cheek out opens the nasal breathing. This can be accomplished surgically through a nasal valve suspension. In this procedure a small incision is made in the curve where the nose joins the cheek and a tunnel is created under the skin to the hair in the temple where another small incision is made. Through this tunnel a small piece of fascia (strong connective tissue) from the leg is passed and secured to either end to secure the nostril in a slightly more open position. Alternatively, the nose can be opened from the inside using traditional rhinoplasty techniques to open the nasal valve with cartilage grafts. In this procedure a piece of cartilage is removed from the nasal septum and inserted under the skin of the nose from the tip of the nose to the cheek. This provides internal support for the nostril and prevents collapse. This can be combined with surgery to straighten the septum if there is a deviated septum as well.
Most people do not notice the muscle activity of the neck until it becomes dysfunctional. The platysmal muscle is a very thin but broad muscle that runs from the lower edge of the jaw bone to the collar bones. The action of this muscle is to tighten the skin of the neck as may be done when a man is shaving. Loss of function of this muscle with facial paralysis is typically not very bothersome or noticeable. When there is facial paralysis followed by incomplete recovery, however, this muscle may become overly tight and contracted or may demonstrated dis-coordinated movement with other regions of the face known as synkinesis. Some people report a tight band extending from the jaw to the collar bone that worsens when they close their eyes or move their mouth. Some portion of this muscle passes over the jaw bone and connects to muscles that pull the corner of the mouth down, so when this muscle is tight it can counteract the desired upward movement of the mouth during a smile.
Treatment of the neck is often focused on relaxing the platysma muscle. This is accomplished through a combination of massage and relaxation techniques, facial retraining, and often Botox® injections. Some people have persistent, troubling platysmal bands and are interested in a more permanent solution than injections. For these patients surgical sectioning of the platysmal muscle may help relieve these bands. This is accomplished through a small incision in a natural neck skin crease. The platysma muscle is isolated and a portion is removed to decrease its function and prevent the ends from growing back together.
Another common issue for patients with facial paralysis is sagging of the lower face and neck on the paralyzed side. For these people a facelift or necklift can help support the facial tissues and improve symmetry with the opposite side.