About Facial Nerve Paralysis

Facial drooping may cause difficulty with facial expressions, such as smiling and closing your eye. It can be classified into one of two types. When the facial muscles are weak and you still have some ability to make facial expressions, it is called paresis. The complete inability to move the muscles of your face is called facial paralysis, where you may see a flattened side of the face without any tone. This usually occurs on one side of the face, and rarely can occur on both sides.


Your facial nerve is responsible for many functions of the head and neck. In addition to weakness (paresis) or paralysis, there are other symptoms that can be associated with facial nerve disorders such as:

  • Decrease in saliva production or a change in tear production
  • Change in your sense of taste on one side of the tongue
  • Sensitivity to loud sounds in one ear
  • Pain around the ear

Frequently Asked Questions About Facial Paralysis


Causes of Facial Paralysis


Bell’s Palsy


One of the most common causes of facial paralysis is Bell’s Palsy. While nobody knows exactly what causes this, it might be related to a viral infection of the facial nerve. It comes on suddenly over 24 to 72 hours (one to three days) and almost always will be on one side of the face. Most people will start to see recovery within 2 to 3 weeks and see a full recovery in three months. It is important to see your health care provider as soon as possible because medications such as steroids and possibly anti-viral treatment given early will help improve your chance for recovery.




Facial drooping can be one of the first signs of stroke. Frequently on one side of the face or body, it can be combined with weakness in the arms and legs, confusion, trouble speaking, vision problems, dizziness, loss of balance or headache. If you are experiencing any combination of these symptoms, call 911 immediately.


Lyme Disease


Lyme disease is caused by ticks. Symptoms of early Lyme disease may present as a flu-like illness (fever, chills, sweats, muscle aches, overly tired, nausea and joint pain) and a rash. Some patients will also develop facial drooping, and this can be on BOTH sides. Because Lyme disease needs to be clinically diagnosed, it is important to see a health care provider if you think you have been exposed or might be infected. Learn more about lyme disease


Brain Tumor


Facial paralysis that is due to a brain tumor usually develops slowly. Symptoms can include headaches, seizures, vertigo (dizziness) or hearing loss, and should be evaluated by an otologist (ear surgeon) or neurosurgeon (brain surgeon). This is commonly called an acoustic neuroma or vestibular schwanomma, although there may be other less common tumors possible. Learn more


Head or Neck Tumor


The facial nerve exits the brain from behind the ear and travels through a large salivary gland called the parotid, located in front of the earlobe. Tumors of the parotid gland, or located in the head and neck, can cause facial paralysis. Learn more about head and neck tumors




Facial paralysis can result from head trauma, which causes either facial nerve swelling or can severing the facial nerve when there is a fracture to the skull. Ramsay Hunt syndrome: This is caused when a shingles outbreak occurs near one of your ears, and may also affects the facial nerve and/or the hearing nerve. It can cause a severe case of facial paralysis in the ear affected by shingles. Prompt treatment can reduce your risk of complications.




The Facial Nerve Clinic can evaluate children born with a facial nerve problem. Present at birth, the most frequent cause of congenital facial nerve paralysis is trauma during the birth process.


Do I Need to See a Facial Nerve Specialist?



The Facial Nerve Clinic sees patients with chronic facial paralysis. This is weakness or any other problem in the facial nerve that has been present for over three months. However, we recommend all patients experiencing new facial nerve weakness that have not been evaluated, see a health care provider immediately. If you cannot schedule with a provider, go to nearest emergency room to rule out any serious cause.


Is There Anything I Can Do to Improve My Recovery During the First Three Months After Experiencing Facial Nerve Weakness or Paralysis?


First, if you have new facial paralysis and have not been evaluated, see a health care provider immediately. You provider may prescribe medications that improve your chance of recovery. After this, it very important to pay attention to your eye to ensure that it is protected.


What Eye Care is Necessary When Experiencing Facial Nerve Weakness or Paralysis?



All types of facial nerve weakness may also affect your ability to close your eyelids. Without taking steps to protect the exposed eye, this could lead to permanent damage. It is important that the eyelids close completely when sleeping and blinking. Major drying of the eye can cause decreased vision, infection, scarring, loss of sight, and loss of the eye in extreme cases. It is very important to use eye protection when the eye cannot close. We recommend all patients see an eye care doctor with incomplete eye closure. You should seek urgent evaluation for any sign of eye irritation which can include: burning, watering, decreased vision, sensitivity to light, and eye pain. More about eye care in facial paralysis


Who Will I See at the Facial Nerve Clinic?


During your appointment with UW Health’s Facial Nerve Clinic, you will be seen by an otolaryngologist (ear, nose and throat surgeon) and occupational therapist with expertise in facial retraining. The Facial Nerve Clinic also has a nurse coordinator to help patients navigate their evaluation and treatment, who will help coordinate any follow up appointments with our team of facial plastic surgeons, neurosurgeons, oculoplastic surgeons, neurologists, head and neck surgeons, and health psychologists who all work together to create the best treatment plan for you. The full evaluation includes intake forms, photographs and a videotape to record your muscle movement, and an evaluation with the Facial Nerve Clinic team.


What Are The Two Types of Chronic Facial Paralysis?


After three months, if the muscles are still weakness, then this is called “flaccid” facial paralysis. However for some patients, as the paralysis goes away, the facial muscles often move incorrectly. This results in facial tightness, spasm, or unwanted muscle movement, called synkinesis. Sometimes, there can be synkinesis AND parts fo the face with weakness called “mixed” facial paralysis. Facial retraining is used for synkinesis to train the facial muscles to once again work in a coordinated and natural way.


How is Chronic Facial Paralysis Treated?


Sometimes facial weakness will go away on its own and takes more time. If the weakness does not go away or you have developed synkinesis, your team may refer you for further treatment. Your treatment will be customized to your specific needs:


Nonsurgical Treatment

Surgical Treatment


If full recovery isn’t obtained through nonsurgical treatments, surgery can often help restore facial function.


Nerve Procedures


Nerve Repair (Direct Neurorrhaphy)


In cases where the facial nerve has been cut, this procedure is performed to directly reattach the injured facial nerve, as long as there is no tension when the nerves are sutured. Muscle movement may not be seen for up to six months while the nerve is regenerating. Although this is the best option for repair of a cut facial nerve, abnormal muscle movement (synkinesis) is likely to develop and may require future facial rehabilitation.


Nerve Grafting


In cases where the cut facial nerve cannot be directly reattached, a jump, or “cable graft” of another piece of nerve can be sewn in place to reattach the injured facial nerve. A nerve “graft” will be taken from behind your ear or from the lower calf and ankle and surgically implanted in your face. This will help restore both movement allowing you to control your facial muscles. Muscle movement may not be seen for six months while the nerve is regenerating.


Nerve Transfer


When you have working facial muscles but the facial nerve branch from the brain does not work, a nerve transfer might be possible. The hope is the donor nerve, such as the masseter nerve that contributes to your chewing or the hypoglossal nerve that moves the tongue, will help to repopulate the facial nerve and produce facial movement, potentially reversing the facial paralysis. For some patients, a “cross-face” restore a spontaneous smile by wiring a nerve connection from the working half of the face to paralyzed areas. The connection is made using nerve graft that is tunneled across the upper lip. In order to avoid weakness on the normal donor side, only certain branches may be donated.


Dynamic Procedures


Dynamic procedures result in dynamic movement, and therefore are called "dynamic."


Free Tissue Transfer


When the muscles of your face have been paralyzed for over long periods of time, new muscle and other tissue can be transferred from other parts of the body to the face, attached to a new blood supply, in addition to the nerve repair procedures. Surgeons often use the gracilis muscle which is found in the upper leg and can be transferred with minimal side effects on walking. Once healed over many months, the new tissue can give shape and volume to the face and can help recreate facial movement, especially the smile.


Muscle Transfer


The temporalis muscle is a chewing muscles located above the ear in the hairline that can improve the ability to smile by connecting a portion of this muscle the corner of the mouth through a tunnel deep in the cheek. Once connected, the biting action can be used raise the corner of the mouth to create a new smile on the paralyzed side.


Static Procedures


Static procedures move parts of the face and secure them in place at the time of surgery. Some can be performed in the clinic or under light sedation.


Lower Face

  • A “sling” is used to raise the corner of the mouth at rest using tissue borrowing material from the thigh or artificial tissues
  • Facelift surgery can improve the tone and drooping of the face seen in facial paralysis
  • Cheiloplasty turns the upper lip out to show more of the natural red part of the lip
  • Lower lip wedge resection surgically removes extra lower lip to improve drinking and spilling of liquids

Middle Region of Face

  • Rhinoplasty surgery can help improve nasal obstruction caused by collapse of the side wall of nose in facial paralysis. Surgery suspends the nose in an open position using a suture or your own cartilage.
  • Cheek “Nasolabial” crease: Facial paralysis often causes the natural crease between the upper lip and the cheek to be abnormal. It can be either too prominent or completely absent and can be adjusted through a suspension with a suture or a graft.

Upper Face

  • Upper eyelid gold or platinum weight placement will aid in eye closure. Because the weight can be taken out at any time, this procedure may be recommended to patients with facial paralysis at any time, without the need to wait three months.
  • Tarsal strip or lateral canthopexy procedures to repair a loose or floppy lower eyelid
  • Brow lift to raise a drooping of the eyebrow

Adjunctive Procedures – Botox


Botox injections are often recommended in addition to other treatments for facial paralysis and abnormal muscle movement, or synkinesis. It is commonly used in conjunction with facial retraining, but Botox can relax over working muscles on the normal side to improve symmetry between the two sides of the face. The effects of Botox are temporary, typically lasting 3 to 4 months and can be repeated as needed.


I’ve Had My Facial Paralysis for Years, Is There Anything That Can Be Done?


After two years into facial paralysis, the muscles begin to break down and can no longer be used to restore strong facial movement. However, there are procedures that can lift sagging/drooping parts of the face or improve eyelid positioning (see static repair), and procedures that transfer new muscle from the upper leg to the face to recreate movement.