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 Facial Paralysis Caused By Trauma or Tumors (Parotid or Acoustic Neuroma/Skull Base)

  • Direct neurorrhaphy (nerve repair): 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 six months while the nerve is regenerating. Although this is the best option for repair of a severed/cut facial nerve, abnormal muscle movement (synkinesis) is likely. Facial rehabilitation can help treat synkinesis.
  • Interposition nerve grafts: When two facial nerve segments cannot be directly reattached in a tension-free manner, an interposition nerve graft can be used. The graft is donated from a sensory nerve behind the ear or from the lower calf and ankle and placed between the segments. Muscle movement may not be seen for six months while the nerve is regenerating. This will leave small areas of numbness at the donation site. Synkinesis is also likely. Other nerve grafts include ansa hypoglossi and the medial cutaneous antebrachial nerve.
  • Free tissue transfer: When large portions of facial tissue must be removed during cancer surgery, muscle and other tissue can be transferred from other parts of the body and attached to a new blood supply, in addition to the nerve repair procedures. The new tissue can give shape and volume to the face. 

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.
  • 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 
  • Sub-periosteal mid-face lift: Improves facial symmetry and can help with nasal obstruction
  • Cheiloplasty turns the upper lip out to show more of the natural red part of the lip
  • 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 

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.