Facial Paralysis
Facial paralysis affects symmetry, expression and basic functions such as closing the eye or smiling. Surgical treatment aims to restore facial balance and, whenever possible, voluntary movement.
When is it recommended?
- Peripheral facial paralysis of traumatic, tumor-related or idiopathic origin (Bell’s palsy) that does not recover spontaneously.
- Sequelae of skull-base or parotid surgery.
- Facial asymmetry at rest or while smiling.
- Difficulty closing the eyelid, posing a risk to the cornea.
- Hyperactivity of the healthy side or synkinesis (associated involuntary movements) that accentuate the asymmetry.
My approach
I trained specifically in facial plastic surgery and reanimation techniques at Sheba Medical Center in Tel Aviv, one of the world's leading centers in this field. Treatment is tailored to how long the paralysis has been present and its underlying cause: assessment with standardized scales (House-Brackmann, Sunnybrook), eye protection when there is a risk to the cornea, botulinum toxin to reduce hyperactivity on the healthy side or synkinesis, and surgical reanimation techniques — static or dynamic, including nerve or muscle transfers — when indicated.
Protecting the eye: the first priority
Before considering any reanimation surgery, the urgent priority is protecting the cornea. When the eyelid does not close properly, the eye is left exposed and exposure keratitis can develop which, if it becomes chronic, may compromise vision. The first measures are simple but essential: frequent artificial tears during the day, lubricating ointment and night-time occlusion. If the problem persists, there are effective surgical solutions: placing a gold or platinum weight in the upper eyelid, which uses gravity to aid closure, and tarsorrhaphy or lower-eyelid tightening procedures when it has dropped and separated from the eyeball. These are straightforward operations with a major impact on quality of life, and they should not be delayed.
Dynamic techniques: restoring movement
The most ambitious goal is recovering a smile that moves. Which technique is chosen depends above all on the time elapsed since the paralysis, because facial muscle atrophies irreversibly after roughly 18-24 months without innervation. If the muscle is still viable, it can be reinnervated through nerve transfers: a cross-facial nerve graft, connecting branches from the healthy nerve on the other side, or masseteric nerve transfer, which offers faster and more powerful recovery. If the muscle is no longer salvageable, the solution is to bring in new muscle: free gracilis muscle transfer, a microsurgical flap implanted in the face and connected to a donor nerve. And when microsurgery is not appropriate, temporalis muscle transposition offers a robust alternative in a single operation.
Synkinesis: when the problem is excess movement
There is a group of patients whose problem is not lack of movement but disordered movement. After a paralysis that partially recovers, nerve fibres can regenerate towards muscles they did not originally supply, and synkinesis appears: the eye closes when smiling, the corner of the mouth moves when blinking, or the neck tightens involuntarily. It is a frustrating situation because, to others, "the paralysis is already cured". Treatment combines botulinum toxin targeted at the overactive muscles — on both the affected and healthy sides, to rebalance — with specific neuromuscular rehabilitation, which retrains the movement pattern taking advantage of the window the toxin opens. In selected cases, selective myectomy or neurectomy surgery offers a more definitive solution.
The emotional impact and why treating it matters
Facial paralysis is not only a functional or aesthetic problem: it affects the way a person communicates and relates to others. The face is the main vehicle of emotional expression, and losing control over it is associated with high levels of anxiety, social isolation and depressive symptoms — well documented in the literature and constantly seen in clinic. Many patients avoid being photographed, eating in public or smiling spontaneously. That is why the goal of treatment is never just "moving the muscle": it is giving the person back the confidence to interact normally. And that is also why it is worth treating cases sometimes considered minor — a mild asymmetry, a bothersome synkinesis — because the improvement in quality of life is usually disproportionately large relative to the size of the intervention.
Recovery
With dynamic techniques, voluntary movement takes several months to establish as the transferred nerve or muscle relearns its function; with static techniques, the improvement in symmetry is visible from the immediate postoperative period. Facial physiotherapy is an essential part of treatment.
Frequently Asked Questions
Does Bell's palsy always need surgery?
No, most cases of Bell's palsy recover spontaneously within weeks or months with medical treatment. Surgery is considered when, after that reasonable window, there are no signs of recovery or significant sequelae remain.
What's the difference between static and dynamic techniques?
Static techniques (such as slings) improve symmetry at rest without restoring active movement; dynamic techniques, such as muscle or nerve transfers, aim to restore voluntary movement, though they require a longer recovery.
How is the degree of facial paralysis measured objectively?
I use standardized grading scales, mainly House-Brackmann and Sunnybrook, which score resting symmetry, voluntary movement and synkinesis. Applying the same scale at every visit makes it possible to objectively track a patient’s progress and decide more precisely on the timing and type of treatment.
Does facial paralysis leave permanent after-effects?
It depends on how badly the nerve was damaged and how quickly it is treated. Around 70% of Bell’s palsy cases recover completely with no trace. In the rest, two kinds of after-effect can remain: residual weakness — the affected side moves less — or, more often than people think, synkinesis, involuntary movements caused by disordered nerve regrowth. The good news is that almost all after-effects are treatable: botulinum toxin, specific neuromuscular rehabilitation and, in selected cases, surgery achieve very significant improvement even years after the initial episode.
What role does botulinum toxin play in facial paralysis?
It is used to reduce hyperactivity in the muscles on the healthy side and synkinesis on the affected side, improving symmetry both at rest and while smiling. Since its effect is reversible, it also lets patients temporarily preview the kind of result surgery could achieve before deciding whether to take that step.