Facial Paralysis Specialists

Facial paralysis usually appears suddenly and worsens over the following 24–48 hours, which is known as the acute phase. Symptoms then persist for a variable period and generally improve progressively with appropriate medical treatment and/or specialised rehabilitation.

Early diagnosis is essential to initiate timely treatment, optimise recovery and prevent long-term functional and aesthetic sequelae.

Depending on the degree of nerve involvement, symptoms may be more or less severe. The primary symptom is difficulty or inability to move the muscles on the affected side of the face.

This results in noticeable facial asymmetry involving eyebrow elevation, eye closure or blinking, and smiling. Patients may also experience difficulty sealing the lips, drinking, chewing, swallowing or articulating certain words or speaking fluently.

Depending on the location of the nerve lesion, additional symptoms may include:

• Ocular symptoms such as reduced tearing, dryness, irritation, burning or a foreign body sensation
• Hyperacusis, or increased sensitivity to sound, making everyday noises particularly uncomfortable
• Loss of taste.
• Headache, jaw pain or pain around the ear on the affected side
• Reduced or absent salivation.
• Difficulty breathing through the nostril on the affected side.
• Beyond physical and functional impairment, facial paralysis alters facial expression and facial movement and often has a significant emotional impact, due to the aesthetic disruption of facial harmony.

The subacute–chronic phase may develop at different stages of recovery and with varying degrees of severity. Close follow-up is therefore essential to plan the most appropriate treatment strategy.

At this stage, rehabilitation focused on voluntary contraction of reinnervated muscles is recommended to improve facial movement and recover affected functions such as eye closure, speech, chewing, facial expression and mimicry.

Conservative management includes:

Medications

Anti-inflammatory medication is prescribed to reduce nerve inflammation. In patients with Bell’s palsy, treatment should be initiated within 72 hours of symptom onset to reduce inflammation of the facial nerve.
In cases of complete paralysis, and when the cause is herpes zoster infection, antiviral therapy is added.

Eye protection

Adequate ocular protection is essential in patients with incomplete eye closure. This initially includes lubricating eye drops and/or ointments, protective glasses, and night-time occlusion using patches or moisture chamber systems.

Rehabilitation

Different therapeutic options may be applied during the various stages of facial paralysis. The mainstay is neuromuscular re-education, a structured exercise programme guided by a specialised therapist, aimed at training facial muscles to improve controlled movement and prevent tone abnormalities.

Stretching exercises are also commonly prescribed, as muscles affected by hypertonia tend to shorten over time.

Injections

Periodic injections of medications that relax hypertonic or hyperactive muscles may be prescribed on one or both sides of the face. Chemical denervation of facial muscles is considered a first-line treatment for controlling asymmetry and, in particular, synkinesis, as an adjunct to physical therapy. Treatment typically begins with low doses, which are adjusted individually based on response. These procedures must be performed by highly qualified medical specialists.

When facial paralysis is caused by nerve transection, nerve reconstruction may be considered in the acute phase using direct suturing or interposition grafts, usually harvested from the greater auricular nerve or the sural nerve (located in the calf).

In cases of complete facial paralysis, when no significant reinnervation has occurred within six months, surgical techniques may be considered to restore nerve signal transmission using donor nerve tissue. Common donor nerves include the hypoglossal nerve (cranial nerve responsible for tongue movement), the masseteric nerve (which innervates the masseter muscle and is involved in chewing and speech), or the contralateral facial nerve.

After two to three years from the onset of facial paralysis, muscle atrophy is likely to develop. To address this, reinnervation using microvascular muscle grafts, typically harvested from the gracilis muscle (also known as the inner thigh muscle), or muscle transposition procedures, most commonly using the temporalis muscle, may be considered.

In addition to these dynamic techniques, static procedures may be performed at any stage of the condition to improve eye closure (eyelid weights or eyelid surgery), nasal airflow (nasal valve reconstruction), or facial symmetry at rest. These include rhytidectomy or lifting of the superficial musculoaponeurotic system (SMAS), static suspension using fascia, or facial lipofilling with autologous fat.

The content of this page has been prepared by the Communication Department and the Medical Team of Grupo Pedro Jaén, in line with our editorial commitment to ensuring the accuracy and up-to-date nature of the information provided.

References on facial paralysis:

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2. Mehdizadeh OB, Diels J, White WM. Botulinum Toxin in the Treatment of Facial Paralysis. Facial Plast Surg Clin North Am. 2016 Feb;24(1):11-20

3. Patel PN, Owen SR, Norton CP, Emerson BT, Bronaugh AB, Ries WR, Stephan SJ. Outcomes of Buccinator Treatment With Botulinum Toxin in Facial Synkinesis. JAMA Facial Plast Surg. 2018 May 1;20(3):196-201

4. Lassaletta L, et al. Parálisis facial: guía de práctica clínica de la Sociedad Española de ORL. Acta Otorrinolaringol Esp. 2019. https://doi.org/10.1016/j.otorri.2018.12.004

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6. Lindsay RW, Robinson M, Hadlock TA. Comprehensive facial rehabilitation improves function in people with facial paralysis: a 5-year experience at the Massachusetts Eye and Ear Infirmary. Phys Ther 2010; 90:391–397

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8. Wei LA, Diels J, Lucarelli MJ. Treating Buccinator With Botulinum Toxin in Patients With Facial Synkinesis: A Previously Overlooked Target. Ophthalmic Plast Reconstr Surg. 2016 Mar-Apr;32(2):138-41

9. Kanerva M. Buccinator synkinesis treated by botulinum toxin in facial palsy and hemifacial spasms. J Plast Reconstr Aesthet Surg. 2021 Jul;74(7):1464-1469.

10. Van Landingham SW, Diels J, Lucarelli MJ. Physical therapy for facial nerve palsy: applications for the physician. Curr Opin Ophthalmol. 2018 Sep;29(5):469-475

11. Cooper L, Lui M, Nduka C. Botulinum toxin treatment for facial palsy: A systematic review.
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12. Alipour S, Pick C, Jansen S, Rink S, Klußmann JP, Grosheva M. Long-term therapy with botulinum toxin in facial synkinesis: Retrospective data analysis of data from 1998 to 2018. Clin Otolaryngol. 2021 Jul;46(4):758-766.

13. Khan AJ, Szczepura A, Palmer S, Bark C, Neville C, Thomson D et al. Physical therapy for facial nerve paralysis (Bell’s palsy): An updated and extended systematic review of the evidence for facial exercise therapy. Clin Rehabil. 2022 Nov;36(11):1424-1449.