Pediatric Facial Paralysis and Möbius Syndrome

Families with a child who has congenital (at birth) or acquired (during or after birth) facial paralysis often have feelings of guilt. But there is no reason to feel guilty. Usually, there is nothing that could have been done to prevent the facial paralysis. In children, facial paralysis “just happens” — it is very rare for facial paralysis to be inherited.

There are more than 100 known causes of facial paralysis. When we make facial expressions (such as smiling, frowning or closing our eyes), the brain sends a signal to the muscles of our face through the pathway of the facial nerve (also known as the seventh cranial nerve). When there is a problem with this pathway, facial paralysis results. Some of the more common causes are outlined on this web page.

Types of Facial Paralysis in Children

Congenital Facial Paralysis
Congenital facial paralysis can occur on one side of the face (unilateral facial paralysis) or both sides of the face (bilateral facial paralysis). Unilateral cases can be caused by, or related to, a number of causes. Other cases of unilateral facial paralysis can be related to conditions such as hemifacial microsomia, in which one half of the face does not develop as fully as the other, sometimes producing less facial motion on the affected side. Goldenhar syndrome is a type of hemifacial microsomia in which other anomalies can be present, frequently involving the eye and the spine.

Bilateral cases often result from Möbius syndrome (also referred to as Moebius syndrome). The exact cause of Möbius syndrome is not known, but it is thought to be related to failure to develop the blood vessels that would normally nourish the facial muscles and nerves. Difficulty in looking laterally (away from the nose) results from paralysis of the eye muscles, which are supplied by the abducens nerve (also known as the sixth cranial nerve). Other nerves also may be involved; these include the glossopharyngeal nerve (also known as the ninth cranial nerve) and vagus nerve (responsible for the gag reflex, also known as the 11th cranial nerve) and the hypoglossal nerve (responsible for tongue movement and known as the 12th cranial nerve). Children with Möbius syndrome are of normal intelligence on average, but because they cannot display emotion as readily as other children, they are sometimes wrongly categorized as learning disabled. Möbius syndrome is sometimes associated with Poland syndrome, a congenital deformity of the chest and hands. We also treat this condition in our group. Möbius syndrome is rarely associated with cleft palate, another condition treated by our group.

Acquired Facial Paralysis
In some cases, babies delivered with the aid of forceps sustain an injury to the facial nerve. In most cases, this injury is temporary and resolves within several months. In other cases, the paralysis can persist, resulting in a difference in movement between the two sides of the face. In some of these cases, we may recommend surgery to improve facial motion. Other forms of trauma also can produce facial paralysis in children including head injury (concussion), cuts that divide the facial nerve and damage to the actual muscles that produce motion.

Sometimes the center in the brain that produces facial motion is injured during removal of tumors, such as acoustic neuromas, ependymomas or medulloblastomas. In many congenital, unilateral cases, we are unable to determine the actual cause of the paralysis.

Treatment of Facial Paralysis in Children

Babies may have difficulty feeding initially. We use special techniques, many borrowed from our experience treating babies with cleft palate, to help in feeding these infants early on (see health information page on feeding an infant with cleft lip and palate). Later, treatment of pediatric facial paralysis is directed mostly toward improving the ability to smile.

In appropriate cases, we recommend reconstructive surgery. We can perform such surgery as early as age five or six.

Unilateral Facial Paralysis

In cases of unilateral facial paralysis, we often are able to perform a nerve graft from the unaffected side to the affected side. This procedure, known as cross-facial nerve grafting, requires harvesting a donor nerve from the patient’s leg (the sural nerve), which usually leaves a small, numb patch on the upper, outer part of the foot. This loss of sensation is typically not of concern to the patient. After nine to 12 months, a donor muscle (the gracilis muscle) is transplanted from the patient’s leg into the face and connected to the transplanted nerve. This procedure requires that the muscle be positioned precisely to produce elevation of the corner of the mouth and upper lip. This procedure is technically very demanding, and it requires the use of microsurgery to connect vessels with sutures (stitches) several times thinner than human hairs. Use of this muscle produces little or no leg weakness (it is a small “extra” muscle). Facial motion usually begins within six months. Although we cannot recreate all the intricate movements of facial expression, we can almost always achieve results providing the ability to smile. The resulting scar is usually barely visible because we use the same type of surgical approach that is used for facelifts. To harvest the nerve from the leg, we typically use two or three cuts (incisions) that are about an inch (2.5 cm) long. These incisions also heal very well and rarely cause problems.

Bilateral Facial Paralysis

In cases of bilateral facial paralysis, it is not possible to connect nerves from one side of the face to the other because both sides are affected. In these cases, we transplant a gracilis muscle to one side at a time, and we use a nerve that assists with chewing. This nerve, the masseteric branch of the trigeminal nerve, is expendable (an “extra” nerve), and using it results in no difficulty in chewing. We usually can do the second muscle transplant three months after the first. We use the facelift-type incision that runs in front of the ear and up into the hairline in the scalp. Usually this incision heals very well, leaving a thin, flat scar. It is not necessary to harvest nerves from the leg for this procedure.

What to Expect the Day of Surgery

We will meet you in the preoperative area, where our staff will make sure that everything is ready for the procedure. It is routine to double check name badges and the side we are treating. The anesthesiology team members will introduce themselves, and then the OR nurse will take your child to the operating room. Depending on what kind of procedure is being done, your child will be in the operating room for between four and 10 hours. Then you will be able to meet your child in recovery and later up in his or her room. Expect your child to be in the hospital for five days or more. If you live far away, we will help you make arrangements to stay at a hotel close to the Medical Center for about a week after discharge from the hospital. Your child will be able to eat and drink using a soft diet as soon as he or she wants. We encourage walking the day after the operation. Your child will be on special medication to help minimize pain and discomfort. Usually children recover from the operation without difficulty.

What to Expect After Surgery

There will be some bruising and discomfort where the nerves and muscles are removed, but usually this can be easily treated with pain medication. There also will be some bruising and swelling in the face. This will improve considerably over the first two weeks. We usually will have a mouth guard in place to prevent damage to the transplanted muscle. This mouth guard will be removed before the child leaves the hospital in most cases. The transplanted muscle may show signs of contracting as early as three months after the operation, but this may not occur for as long as six months and sometimes even longer. We will see your child back in the plastic surgery clinic, and we will provide coaching on how to do facial exercises to strengthen the transplanted muscle.

For a patient appointment, please call 1-800-283-5848.

Further reading:

  1. Borschel GH. Facial paralysis. In: Brown DL and Borschel GH (editors-in-chief). The Michigan Manual of Plastic Surgery. Philadelphia: Lippincott, Williams and Wilkins, Inc.; 2004.
  2. Westin LM, Zuker R. A new classification system for facial paralysis in the clinical setting. Journal of Craniofacial Surgery. 2003 Sep;14(5):672-679.
  3. Bae YC, Zuker RM, Manktelow RT, Wade S. A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plastic and Reconstructive Surgery. 2006 Jun;117(7):2407-2413.