Guest post by:
Samuel L. Oyer, M.D. 
Specialist in Facial Plastic and Reconstructive Surgery
MUSC Health ENT

Facial paralysis is a devastating condition with a wide variety of causes. Although this condition is uncommon, it can profoundly affect a person’s facial function related to vision, nasal breathing, speech, swallowing, and emotional expression. Equally impactful are the effects on a person’s appearance, social interaction, and psychological function which can lead to poor self-esteem, isolation from social activities, and depression. Facial paralysis affects every person differently. Some people recover completely without intervention, others recover partially but are left with troubling impairments, and some have absolutely no recovery. Too often, patients are told that “there’s nothing more that can be done” for their problems or that their amount of recovery is “good enough.”

The goals of treatment of facial paralysis include limiting the symptoms associated with paralysis, improving the functional deficits, and restoring as much facial symmetry as possible to minimize the impact on a person’s quality of life. This in turn improves not only the physical, but also the social, emotional, and psychological aspects of the condition.

The treatment options for facial paralysis are as varied as the many causes of the disorder. These can include medication, physical therapy, injectable treatments such as Botox or filler, and surgery. There is not a simple recipe for treatment because every patient is different, and often a combination of treatments are recommended. Patients who are engaged and actively participate in their own recovery tend to do better, regardless of treatment type, than those who take a more passive role.

While facial paralysis often affects one entire side of the face, much attention is given to restoring a person’s smile. A smile is an integral part of a person’s identity and loss of a smile not only impacts a person’s ability to express emotion, but also impairs how that person is perceived by others. Older treatments focused on fixed suspension of the paralyzed side of the mouth with a sling to improve facial symmetry, but contemporary treatment aims to restore not only the position of the mouth but also movement of the mouth to recreate a smile whenever possible. Depending on the type of paralysis, this is often best achieved by replacing the damaged facial nerve with a different, functional nerve.  

The facial nerve travels from its origin in the brain and exits the skull beneath the ear before passing through the parotid gland and dividing into numerous branches across the face to supply over a dozen muscles on each side. It serves as the power source to the muscles, much like an electrical cord plugged into an outlet. When the facial nerve is damaged and can no longer signal the muscles to move, a different nerve can be used as a power source for the facial muscles like splicing in a new cord from a different outlet. This only works if the attachment between the facial nerve and muscles is intact and is limited to the first one to two years following onset of paralysis. Donor nerves can come from the intact facial nerve on the opposite side of the face or from a nerve normally directed at a jaw or tongue muscle such as the masseteric or hypoglossal nerve. This nerve transfer takes up to six months to begin working after surgery, but can help restore tone to the facial muscles and movement of the natural muscles that create a smile.

If too much time has passed since paralysis or there is no more connection between the facial nerve and muscles, then a different source of movement must be used to recreate a smile. This involves repositioning a different muscle with its nerve supply from adjacent areas in the face or from distant areas in the body. The temporalis muscle is a chewing muscle that connects the lower jaw to the side of the head above the ear. This muscle can be detached from the lower jaw and attached to the corner of the mouth to suspend it. This means that when that person clenches his or her jaw, the muscle tightens and lifts the corner of the mouth in a smile. Another alternative is to transplant a muscle from the inner leg to the face. This muscle connects to the corner of the mouth and is attached to an artery and vein in the neck for blood supply along with a nerve graft to the opposite side of the face or to the masseteric nerve on the same side. After a period of four to six months the nerve attachment will allow movement of the transplanted muscle to create a smile on the paralyzed side.   

Although none of these treatments perfectly restores what has been lost in facial paralysis, each can help improve the dynamic motion of a lost smile and rebalance facial symmetry as part of an overall treatment plan. Additional treatments may be involved to help improve symmetry and function around the nose, eyes and forehead. Each of these is tailored to the specific needs of the individual. With proper treatment, many of the negative impacts of facial paralysis can be improved allowing people affected by this condition to maintain a good quality of life and remain active in their work and social lives.