Treatments for Facial Paralysis

UW Health's Facial Nerve Clinic at UW Hospital and Clinics in Madison, Wisconsin, provides a multidisciplinary approach to diagnosing and treating facial paralysis in children and adults.

 

 

Medication

 

In many cases of facial nerve weakness, providers may prescribe an oral steroid that will help to reduce inflammation (irritation) of the facial nerve. Multiple research studies have shown that high doses of medication, started within 72 hours of the paresis (weakness) or paralysis, will improve chances for recovery.

 

If you cannot be seen by your doctor for new facial weakness, you should proceed to the nearest emergency room so that the emergency doctor can rule out other serious causes and discuss medications with you.

 

 

Early Surgery for Facial Paralysis

 

If the onset of paralysis was fewer than 14 days ago: Talk to your primary care providers about seeing an otologist. These ear surgery specialists can perform electroneuronography testing (ENOG) to determine if you are a candidate for facial nerve decompression. This operation may be helpful for individuals whose facial nerve has become so inflamed that it is compressed in the tight space near the inner ear. Research suggests that releasing this nerve in a timely manner can lead to improvement in facial paralysis symptoms.

If paralysis has been present for longer than 14 days but fewer than three months: Since most cases of Bell’s palsy have an excellent chance for recovery, specialists recommend that patients rest the affected area for at least three months after initial consultation and no therapies should be considered aside from oral medication. Certain precautions may be recommended if you have incomplete eye closure.

  • You may be a candidate for a small procedure to insert a metallic weight into your upper eyelid to aid in eye closure. Since the weight can be removed at a later time, this can be placed in special circumstances of facial paralysis where there is a good chance of recovery but profound difficulty in eye closure.
  • Botulinum (Botox) injections may also help with eyelid closure for up to three months. However, most patients use other methods of eye care and undergo these procedures only for continued difficulty with eye closure at three months. (See eyelid section under important patient information)

 

 

Treatment for Chronic Facial Paralysis

 

If paralysis has been present for more than three months: You should be seen for a comprehensive evaluation at the UW Health Facial Nerve Clinic. We may perform electromyography testing (EMG) in cases where it is not clear if the facial muscles are recovering or order other imaging tests. The facial nerve team may recommend surgery or physical therapy that can help alleviate the residual effects of paralysis both functionally and cosmetically.

There are two types of facial paralysis that have been present for more than three months (chronic): flaccid facial paralysis and synkinesis.

  • Flaccid Facial Paralysis: Facial paralysis causes weakness to many muscles of the face. In flaccid paralysis, all muscle tone is lost and no movement exists, resulting in eyebrow and lower eyelid droop, inability to close eye, midface sagging, nasal twisting and obstruction, lower face droop with sagging at the corner of the mouth, difficulty eating, and inability to smile.

 

  • Synkinesis After Facial Paralysis: Although many patients with flaccid facial paralysis will see improvement, sometimes the facial muscles can "over-correct" causing the face to become tight, stiff or "heavy." The eye may appear small. The crease between the side of the nose and corner of mouth (nasolabial fold) may seem deeper than the unaffected side. In some cases, the facial nerve can heal improperly causing muscles to contract out of sequence at the same time. For example, the eye may close during a smile or pucker, or the cheek may pull up when the eye closes. This improper movement, called synkinesis, can result in uncoordinated or distorted facial expression.

 

 

Treatment for Synkinesis

  • Facial retraining may improve expression through muscle coordination
  • Botulinum toxin has been shown to temporarily reduce facial spasm and improve synkinesis
  • The UW Health Facial Nerve Clinic specializes in treatment of synkinesis
Facial Never Surgery - Before Treatment Facial Nerve Surgery - After Treatment
Before Treatment After Treatment

 

This 48-year-old female underwent surgery to remove a large tumor on her hearing & balance nerve called a vestibular schwannoma (acoustic neuroma) in October 2016.  After 15 months of recovery, she presented to the UW Facial Nerve Clinic with significant difficulty with smiling and eye closure due to synkinesis of the left facial muscles with weakness of the upper face. She underwent specialized neuromuscular retraining therapy sessions with Jackie Diels, OT for treatment of her synkinesis.  Functional Botox (onabotulinumtoxinA) injections performed by Dr. Scott Chaiet were added to treat the muscles of the neck and around the eye with synkinesis.

 

 

Types of Surgery for Facial Paralysis

 

UW Health's Facial Nerve Clinic at UW Hospital and Clinics in Madison, Wisconsin, provides a multidisciplinary approach to diagnosing and treating facial paralysis in children and adults.

 

Types of Surgery

 

Surgery for Chronic Facial Paralysis: Nerve Transfers

 

"Nerve transfers" are performed when there are working facial muscles and nerve branches that cannot be connected to the main facial nerve exiting from the skull.

  • Cross-facial reinnervation procedures are performed by wiring new nerve connections from facial nerve branches on the working half of the face to paralyzed areas. The connection is made between branches of the facial nerve to a sural nerve graft from the lower calf and ankle, tunneled across the face under the nose, and connected to the distal nerve branches of facial muscles on the paralyzed side. In order to avoid paralysis on the normal donor side, only certain branches may be donated.
  • The masseteric nerve can be connected to the facial nerve to give movement to the face, resulting in the loss of function of one of the muscles involved in chewing but typically not significant weakness. The most frequent use of this nerve is for the restoration of the smile.
Facial Never Surgery - Before Treatment Facial Nerve Surgery - After Treatment
Before Treatment After Treatment

 

In March 2015 this patient had emergency surgery to repair a brainstem bleed that left her a quadriplegic and with facial paralysis. After two years, she regained function of her limbs, but had only a return of tone to the face and some movement of the lips. Dr. Aaron Wieland performed facial reanimation surgery including a “5-7” nerve transfer from the right masseter muscle to the face. She is now able to smile by biting on the right side and has improved resting symmetry.

  • The hypoglossal nerve can be used as a nerve donor on the same side of the paralysis. This may result in tongue changes with speech and swallowing difficulties, so only a portion of the hypoglossal nerve is borrowed to stimulate the facial nerve muscles. Often a nerve graft (greater auricular nerve) is connected from the facial neve to the side of the hypoglossal nerve.  

 

 

Surgery for Chronic Facial Paralysis: Static Procedures

 

Between one and two years into facial paralysis, the muscles begin to break down and can no longer restore movement. However, static procedures can lift sagging/drooping parts of the face or improve eyelid positioning.

 

Lower face:

  • Static sling to raise the corner of the mouth at rest using tissue  from the thigh or artificial tissue such as Gore-Tex
  • Facelift 
  • Lower lip wedge resection/surgical removal 

Middle region of face:

  • Nasal obstruction: Facial paralysis coincides with a loss of muscle tone that supports the lower nose, resulting in nasal collapse. This can be corrected by suspending the nose in an open position using a suture or a graft.
  • 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 
Facial Never Surgery - Before Treatment Facial Nerve Surgery - After Treatment
Before Treatment After Treatment

 

This 69-year-old patient arrived at the Facial Nerve Clinic with untreated left sided synkinesis as a result of facial paralysis caused by Bell’s palsy 35 years prior. She could not raise the left side of her mouth to smile and had asymmetric drooping of her eyebrows causing vision impairment.  She also underwent an endoscopic brow lift and bilateral upper lid blepharoplasty surgery with Dr. Scott Chaiet.  To treat her synkinesis, she underwent neuromuscular retraining therapy with Jackie Diels, OT and functional Botox (onabotulinumtoxinA) injections.

 

 

Surgery for Chronic Facial Paralysis: Dynamic Procedures

 

Dynamic procedures, like static procedures, can be used when facial paralysis has been present long enough that muscles begin to break down and can no longer restore movement. Static procedures can improve the position of facial tissue at rest and result in new movement like smiling.

 

In free tissue transfers, distant muscle and nerves can be transferred from other parts of the body and attached to a new blood supply, such as the gracilis muscle from the thigh, the pectoralis minor muscle from the chest or a muscle from the back. The transferred nerve can be attached to the proximal facial nerve or to a crossover nerve graft connected to the non-paralyzed side, and finally to a motor nerve borrowed from a chewing muscle.

 

If the proximal facial nerve is intact, this procedure may result in a more spontaneous smile. The cross face nerve graft can also result in a spontaneous smile, but does require two surgeries and the results take longer to achieve. The masseteric nerve leads to the most rapid return of motion to the transferred muscle and has the benefit of a strong neural input.