Advanced Expertise in the Diagnosis and Treatment of Facial Paralysis

• Antivirals. When facial nerve paralysis is caused by a virus, the symptoms are usually due to inflammation and swelling which can restrict blood flow to the facial nerve. Oral antiviral medications stop the virus from multiplying and spreading, relieve the inflammation and restore normal blood flow - allowing the nerve to heal and return to normal function.
• Corticosteroids. Steroid medications may be prescribed to reduce inflammation and swelling around the facial nerve. Usually they are taken orally for 10 to 14 days although in some cases a more aggressive approach to treatment may be required. For example, if your doctor suspects that your symptoms are causes by the herpes zoster virus (shingles), a stronger dose delivered intravenously may be the first step, followed by a course of oral medication for 7 – 10 days.
• Analgesics. If there is pain associated with your facial nerve inflammation, your doctor will recommend the appropriate pain medication(s) as part of your total treatment plan.
• Eye Drops. When facial nerve dysfunction affects the ability to blink and/or fully close the eyelid, keeping the eye lubricated is an essential part of treatment. In addition to using eye drops frequently throughout the day, your doctor may recommend the use of a lubricating gel at night, with the eye taped shut.

They may be used separately or together to enhance facial movement, function and cosmetic appearance.

• Botulinum toxin or Botox^® has been used for many years to relieve facial tightness and improve facial symmetry by weakening or paralyzing certain muscles in the face. It is most commonly used to treat tightness around the eyebrow, mouth, cheek and neck or to improve facial symmetry by weakening the muscles of the non-paralyzed side of the face. The effect is temporary, lasting approximately 3 – 6 months but can be repeated every 4 – 6 months if the results are beneficial to the patient.
• Facial fillers are used to add volume and restore symmetry to areas of the face affected by muscle atrophy. They can also be used to treat certain functional problems – for example, injecting filler around the lip can help resolve recurrent lip biting or drooling and improve certain speech problems. Facial filler treatments are typically done in the doctor’s office with local anesthesia and may last up to 18 months or more.

At University Hospitals, our team of physical, occupational and speech therapists carefully evaluates each patient and develops a personalized plan of care based on their diagnosis, prognosis and the severity of their condition. The goals of therapy are to:

• Stimulate, strengthen and retrain the facial nerve and supporting muscles to improve facial coordination
• Improve facial symmetry
• Regain or refine facial movements for specific functions such as speaking, eating and closing the eye
• Restore the ability to smile, frown and other facial expressions
• Correct abnormal patterns of facial movement

These goals are achieved through a series of special exercises designed to retrain the brain to coordinate the facial muscles more effectively. Our therapists take the time to teach each patient how to do the exercises properly and how often to do them for the best possible outcome.

Although often considered cosmetic, these surgical procedures have been shown to help relieve symptoms and improve function in certain patients with facial paralysis. These procedures include:

• Facelift
• Forehead/brow lift
• Eyelid surgery (blepharoplasty)
• Rhinoplasty

Facial paralysis that prevents the eye(s) from fully closing can put the eye at risk for excessive dryness and loss of sensation, which can ultimately lead to eye ulceration and infection. If nonsurgical treatments such as eye lubrication and external eyelid weights are not sufficient, we offer a surgical procedure to correct eyelid closure. During the surgery, we place a thin platinum weight under the upper eyelid skin to help achieve better descent of the eyelid and full eyelid closure. The weight can be removed at any point if it is determined it is no longer required.

When the facial nerve is compressed by surrounding bone or muscle due to injury or disease, the associated facial muscles can become numb or paralyzed. Decompression surgery removes whatever is pressing on the nerve to relieve the pressure, improve blood circulation and restore feeling and function. Nerve decompression surgery is most effective for acute episodes of facial paralysis in which symptoms have been present for less than three weeks.

If the facial nerve itself is diseased or damaged, a direct nerve repair may be a good surgical option. In this procedure, the affected segment of the nerve is removed and the two nerve ends reconnected. If there is not a sufficient length of nerve to reconnect the ends, a piece of nerve taken from elsewhere in the body may be used to “bridge” the gap created once the injured portion is removed. This is called a nerve graft.

This procedure involves taking a sensory nerve from the neck, arm or leg and attaching it to a facial nerve branch on the non-paralyzed side of the face, tunneling it across the face and connecting it to nerves on the paralyzed side to restore function.

This procedure involves dividing the masseteric nerve (which runs through the muscle we use for chewing) and connecting one end to a branch of the facial nerve. This procedure is a reliable way to restore movement of the lip and cheek on the paralyzed side.

This procedure involves dividing the hypoglossal nerve (which controls tongue movement) and attaching one end to the facial nerve to improve facial tone and symmetry. There is some risk of tongue weakness following this procedure but this can often be resolved with appropriate therapies.

The temporalis muscle lays over the side of the skull and attaches to the jaw to help close the mouth and clench your teeth together. We can provide movement to the corner of the mouth by detaching this muscle from the jaw and re-attaching it to the lip. The beauty of this procedure is it can be hidden either through an incision in a crease on the cheek or in the mouth. Once it has healed, the lips will be in better position and the corner of the mouth will move up with clenching (similar to a sile). We usually overcorrect the smile at first because over time this muscle relaxes to provide great symmetry. As one can imagine, clenching your teeth is how you would control the muscle and that means the patient needs retraining and rehabilitation to get the best outcome from surgery.

The gracilis free flap takes a muscle from the leg and transfers it to the face. We reattach both blood and nerve supplies to achieve healthy and desirable movement. This procedure often involves two stages of surgery separated by 6 – 8 months. We perform these surgeries through incisions hidden along the hairline and around the ear similar to a facelift surgery. The first stage of surgery takes a nerve from the side of the leg to attach to a facial nerve on non-paralyzed side of the face. We tunnel this nerve across the face to be primed for the next stage of surgery that is the muscle transfer. For the second surgery, we attach the gracilis muscle to the previously tunneled nerve, as well as a second nerve we use to chew (the masseteric nerve). This provides the mouth muscle with coordinated and strong movement, leading to more facial symmetry. The muscle takes up to 6 months to begin moving and continues to improve with retraining and rehabilitation over the next few years.

Muscle myectomy is a surgery involving removal of a muscle that is moving unfavorably, commonly seen in patients who experience a limited recovery after facial paralysis. The most common reason for this procedure is to treat muscles around the mouth or neck that are pulling the corner of the lip down, leading to discomfort or an abnormal smile. A myectomy can remedy this by removing a portion of the dysfunctional muscle. Often, we would first inject Botox^® into these muscles to temporarily weaken them and investigate if a myectomy would be effective as a long-term option.

Abnormal, uncoordinated muscle movements of the face (synkinesis) is often due to abnormal nerve activity in patients who experience a limited recovery after facial palsy. Neurectomy is a procedure during which we excise the specific nerves that are no longer communicating properly with the facial muscles The malfunctioning nerves are identified and either cut out or rerouted to improve facial movement. Similar to myectomy, we will often try Botox^® injections first to ensure a neurectomy is necessary for an optimal outcome.