Facial expression is integral to our ability to express emotions and to communicate with others. Facial paralysis, or the inability to move the facial muscles, can be a very upsetting condition, regardless of cause, duration or age.
Questions & Answers
The emotional and social implications of this facial difference can be immense, sometimes even greater than the physical consequences. The physical consequences of facial paralysis are well-known. People may experience eye irritation from the abnormal function and position of the eyelids. Eye irritation, excess tearing, blurred vision, corneal ulcers and repeated infections may occur. The affected eye may have a larger appearance. The affected portion of the face may droop, which often is more pronounced with increased age. The nose may be partially collapsed on the affected side, making nasal breathing more difficult. In cases of paralysis on one side of the face (unilateral), with attempted smile, the mouth on the affected side of the face is often pulled to the normal side of the face because of the force of the normal smiling muscles. In cases where both sides of the face are affected (bilateral), the lips may not move at all. The affected lips have poor movement and support, which can result in difficulties with speech (especially sounds like “p” and “b”) or drooling.
Facial expressions are controlled by the facial nerve, or cranial nerve VII. The facial nerve extends from the brain, travels through a portion of the skull (the temporal bone), courses through the cheek, and branches to the many muscles of facial expression. There are five main facial nerve branches that go to the forehead, eye, cheek and nose, mouth, and neck. There is one facial nerve pathway on each side of the face (left and right). 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. Interruption anywhere along this pathway may result in facial paralysis.
There are more than 100 known causes of facial paralysis. Some of the more common causes of facial paralysis are listed in the table.
Some causes of facial paralysis improve and even resolve spontaneously and some do not, some are present at birth and some occur later in life. Facial paralysis may be associated with other differences or syndromes or occur in isolation. Facial paralysis may be unilateral (one-side) or bilateral (affecting both sides) and may affect people of all ages. Paralysis may involve the entire face or only a portion of it.
To better define the cause and extent of the facial paralysis, occasionally specific tests are necessary. These provide valuable information about the type of nerve injury and may help to predict the possibility for recovery.
Electroneurography (ENOG): ENOG records a compound action potential of facial muscles after maximal stimulus of the facial nerve near the base of the ear. ENOG is useful in predicting which patients will have a poor outcome. This test is used within the first 3 weeks of facial paralysis onset.
Electromyography (EMG): EMG may be useful in determining the extent of nerve injury and therefore the potential for spontaneous recovery. EMG may also be helpful in determining appropriate nearby donor nerves in cases of multi-nerve dysfunction. EMG is most useful after 3 months from the time of facial paralysis onset.
Magnetic Resonance Imaging (MRI): Imaging studies may be indicated to visualize the path of the facial nerve in some cases.
Facial palsy is a complex condition. The facial paralysis team at St. Louis Children’s Hospital and Barnes-Jewish Hospital provides comprehensive care and may involve a multidisciplinary team approach. Initial consultation is often with the reconstructive surgeon, Dr. Alison Snyder-Warwick. Consultations with ophthalmologists, speech pathologists, physical and occupational therapists, neurologists, otolaryngologists (ear, nose and throat physicians), and developmental psychologists may be beneficial, depending upon individual circumstances.
Treatment for people with facial paralysis is variable and depends upon individual circumstances, particularly cause and duration of the facial paralysis, potential for improvement, and the desires and overall health of the affected person. Management of facial paralysis may or may not involve surgery. Today, there are many modalities available to assist a person with facial paralysis, including multiple different types of surgeries. Physical therapy, massage and chemodenervation (botulinum toxin) may provide benefit in certain scenarios, either alone or in combination with surgery.
For all individuals, we attempt to prevent or treat the functional consequences of facial paralysis as much as possible. For example, great care must be taken to protect the eye from increased exposure. Lubricating drops and ointment are frequently used, and sometimes more protective techniques are employed, particularly at night. Surgery may be necessary for eye protection alone in certain circumstances. In cases of acquired facial paralysis, a course of steroids or anti-viral medication may be indicated.
Of main consideration regarding the optimal management for a person with facial paralysis are the cause and duration of the paralysis. In cases of congenital (present since birth) facial paralysis, the facial nerve and facial muscles may not have developed appropriately or may be absent. Attempting to provide a new nerve source to these muscles, then, is not logical or possible, but other types of reconstruction are possible. In cases related to an injury, the facial nerve and muscles may be present and of normal structure, just not in continuity. Once a muscle has lost its nerve source for any reason, there is a window of opportunity to provide a nerve to those original muscles. After that window has passed, usually about 12-24 months, the original muscles can no longer accept a nerve. In those cases, a nerve supply as well as new muscle must be provided.
There are many possibilities for reconstruction after facial paralysis. Reconstruction may be static—meaning that it acts as a support for the face for a more symmetric appearance at rest, but cannot move—or dynamic, meaning that movement is possible. In cases where the muscles are normal and the paralysis is recent, the reconstruction is focused on the nerve supply. Nerve grafts or transfers may be used to recreate a nerve connection to an otherwise normal muscle. In cases of long-standing facial paralysis, new muscle and a new nerve supply must be established. Reconstructions are tailored to each person’s unique circumstance. Additional generalized information about these techniques is listed on these pages: Reconstruction Before Critical Window of Muscle Denervation and Reconstruction After Critical Window of Muscle Denervation.
Facial evaluation and reconstruction is considered by facial region. Brow elevation, eye closure, nasal function, smiling and lip depression are considered. Many modalities may be involved to provide improvement to each region, and recommendations may vary by region. To date, the best dynamic reconstruction techniques available involve the ability to smile.
It is important to realize that facial nerve reconstructions rarely result in an appearance identical to the pre-injury state or similar to a person unaffected by facial paralysis. Although it is not possible to recreate all of the intricate movement of facial expression, many excellent techniques are available for smile reconstruction. Reconstructions do typically improve function and appearance, although success is never guaranteed. Achieving greater symmetry and the individual’s personal goals are emphasized.
Timing for surgery is dependent upon the individual circumstances. The duration of facial paralysis guides the appropriate treatment.
The surgical procedures involving the face utilize an incision similar to that used for facelifts. The incision runs vertically directly in front of the ear and extends into the hairline and slightly below the jawbone. This incision typically heals nicely, eventually resulting in a thin, flat scar. For procedures requiring the sural nerve for a nerve graft, two or three small (approximately 2.5cm) transverse scars are created on the back of the calf. These incisions also typically heal very well. For muscle transplants, a segment of the gracilis muscle from the inner thigh is used. The scar is a straight line on the inner aspect of the thigh. This scar may become somewhat wider and more raised compared to the other scars.
How Can I Learn More?
To schedule an appointment with Dr. Snyder-Warwick, please call 314-362-7388. Additional information may be obtained from the following articles:
- Fattah A, Borschel GH, Manktelow RT, Bezuhly M, Zuker RM. Facial palsy and reconstruction. Plastic and Reconstructive Surgery. 2012 Feb; 129(2):340e-352e.
- 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.
- Singham J, Manktelow R, Zuker RM. Mobius syndrome. Seminars in Plastic Surgery. 2004 Feb; 18(1):39-46.
- Zuker RM, Goldberg CS, Manktelow RT. Facial animation in children with Mobius syndrome after segmental gracilis muscle transplant. Plastic and Reconstructive Surgery. 2000 Jul; 106(1):1-8.
There are many excellent patient and family groups focused on facial paralysis, facial differences, and specific diagnoses. Some people find these resources helpful. Links to some of these resources are listed below.
About Face Canada
Ameriface (Formerly About Face USA)
American Cleft Palate-Craniofacial Association
Children’s Craniofacial Association
Children’s Rare Disease Network/The Global Genes Project
FACES: The National Craniofacial Association
The Möbius Syndrome Foundation
National Organization for Rare Diseases (NORD)