Facial Palsy refers to the paralysis of the facial muscles because of damage to the facial nerve. Missing or damaged facial nerve means the facial muscles do not receive signals and hence do not function properly.
In such cases, eyes and/or mouth, along with other areas, are affected. In addition, the varying degrees of facial paralysis, such as only the lower half of the face are affected or a single side of the face is affected, or both the sides of the face are affected.
Dr. Leena Jain is a plastic surgeon in Mumbai who treats patients with facial palsy and here she shares insights on Facial Palsy and its treatment.
About the facial nerve
The facial nerve is also known as cranial nerve VII; it is the nerve of facial expression. It comprises approximately 10,000 neurons, including 7,000 myelinated and innervated nerves of facial expression.
The facial nerve arises from the brain and the upper spinal cord, and it is connected with the nerves of the head and neck while it exits into the face around the ear. It also passes into the parotid gland and supplies several facial muscles required for expression.
The facial nerve includes general sensory fibres, special sensory fibres, autonomic motor fibres, and somatic motor fibres. These fibres transmit signals to and fro from the various areas of the face and the brain.
Some of these nerves located in the anterior2/3 part of the tongue are involved in taste and in producing tears. In addition, the small branches of this nerve helps in noise sensitivity.
Facial paralysis occurs due to several reasons -
By birth –
The damage to the nerve occurs just before or at the time of delivery for unknown reasons. For example, a difficult delivery can damage the facial nerve. At times, the use of forceps can also damage the facial nerve.
Facial Palsy can occur due to a stroke. The type of stroke determines the damage to the brain cells. The damage to the brain cells is either due to a shortage of oxygen or more pressure on the brain cells on account of bleeding.
Tumors of ear and/or parotid gland -
In case of surgery to remove the ear and/or parotid gland tumors, there is a risk of damage to the facial nerve as it travels through the parotid gland. Total Parotidectomy surgery is a complex procedure in which, along with the entire parotid gland, a section of the facial nerve is removed, and hence results in Facial Palsy.
Infection of the middle ear –
An infection in the middle ear can lead to changes in the microenvironment of the middle ear such as acute inflammation, retrograde inflammation, osteitis, elevated pressure, presence of active viruses in the bony facial canal wherein the facial nerve is located, and likely to be affected.
Injury to face or head trauma –
Injury to the temporal bone through which the facial nerve travels can lead to facial Palsy. In head trauma such as assault, falls, accidents, and more, the bony channel gets crushed or swells up, resulting in either temporary or permanent damage to the facial nerve.
Spontaneously as in Bell's Palsy –
Multiple viral Infections such as HSV-1, CMV, and EBV are considered to cause Bell's Palsy, though exact causes are still unknown. Moreover, Bells's Palsy is identified as a spontaneous, acute, unilateral weakening of facial muscles due to unknown reasons.
A patient in this condition will experience loss of facial movement as the facial muscles decrease their capacity to function. As a result, the facial muscles in the affected area are likely to droop gradually. The duration of the paralysis can be either long or short. Hence, an accurate diagnosis is necessary to ascertain the exact cause and extent of facial Palsy.
Symptoms of Facial Palsy
Facial palsy occurs on one side of the face, and it is characterized by pulling of the opposite side working muscles. Facial Palsy patients cannot raise eyebrows, close eyes, smile, or pout as the mouth is twisted. The patients also complain of trouble in talking, headache, dizziness, sensitivity to noise, twitching of muscles, etc.
Age and facial palsy
Facial Palsy can affect newborns, young and old as well. If the paralytic condition is not treated correctly, the patients develop eating and speech problems leading to low self-esteem. Hence, seeking the most suitable treatment is necessary.
The course of the facial palsy
Spontaneous recovery in few cases
The patient can experience spontaneous recovery in the case of Bell's Palsy, Guillain-Barré syndrome, and Ramsay Hunt syndrome though the extent and degree of recovery are not predictable. However, complete recovery is not assured.
The patient is likely to recover within first three weeks after experiencing facial palsy. During the initial recovery stages, the muscle will be weak and floppy, referred to as the flaccid stage. In the second stage, or the paretic stage, the muscles regain their shape, tension and patient can make small, spontaneous movements followed by complete recovery in the following weeks.
Incomplete or partial recovery is noted within two-three weeks after the palsy. Therefore, it is essential to ascertain the cause, duration of paralysis, and its degree to decide the most comprehensive recovery plan. The focus is to prevent development of asymmetry, synkinesis, contracture, and hypertension, and this condition mentally affects the patient to a great extent.
The focus of the treatment is to preserve and restore the face and its functioning in the best possible manner. There are numerous rehabilitation options available for partial recovery cases. The Botulinum toxin injection shows promising results however, may need to be repeated.
If no improvement is noted within two to three months after the palsy attack, an abnormal facial function is associated with delayed recovery. In addition, the patient can develop asymmetry, synkinesis, contracture, etc. Synkinesis refers to unwanted muscular contractions of the face on movement e.g., closure of eyes when attempting to smile or involuntary muscle spasms when the patient moves their face.
Patients and family members can visit Dr. Leena Jain for consultation at her plastic surgery clinic in Mumbai. She is easily approachable and highly understanding and explains the nerve surgeries and their likely outcome.
Treatment of Facial Palsy
Early treatment of Facial Palsy is recommended, especially within two weeks of its onset. Early-stage or intermediate facial palsy patients are suggested to attempt facial muscles retraining, massages, and exercises to maintain their condition.
Facial paralysis prevents desired facial expression, symmetrical smile, communication, speaking abilities, and eye protection. Also, each patient is affected differently. Therefore, the treating plastic surgeon should conduct an in-depth examination to determine the cause, duration, and extent of paralysis. Early-stage facial palsy patients need to approach neurologists for facial nerve decompression treatment after ascertaining the cause of palsy.
For a patient with facial paralysis for more than three months, the plastic surgeon recommends electromyography testing (EMG) and specific therapy to treat after-effects of the disease functionally and cosmetically. Plastic surgeons perform nerve transfer surgery, an advanced cosmetic procedure for patients whose nerve branches and working facial muscles cannot be linked with the primary facial nerve.
Plastic surgery is recommended for patients with chronic facial paralysis. The multidisciplinary team, with the plastic surgeon being the key person, plans a comprehensive recovery plan and chooses the most suitable plastic surgery for the best outcome. The most preferred approaches include direct facial nerve repair with or without muscle transfer, cross-facial nerve grafting, nerve transfer, grafting, etc.
Dr. Leena Jain is a leading plastic surgeon in Mumbai who performs facial reconstruction or facial reanimation surgeries.
Facial Nerve Repair –
The surgeon performs the facial nerve repair as and when possible, usually in cases of acute injury to nerve. The focus of the procedure is to identify the cut ends of the nerve or its branches and reconnect them.
Facial nerve grafting –
In cases of acute nerve injury with a gap as can occur during injury or during surgery, the surgeon uses a piece of nerve graft from elsewhere like nerves in the leg or in the forearm to bridge the gap. The surgeon then uses tiny sutures to graft paralyzed nerves to healthy ones.
Cross face nerve graft –
In cases, presenting late after about more than a year, the surgeon takes healthy donor nerve from another part of the body and connects one end to muscles on the affected side of the face while the other end is connected with the functioning nerve branches on the unaffected side. A nerve graft takes nearly a year to regenerate, followed by improvement in muscle control in some cases; in most other cases the second stage of muscle transfer is required.
Nerve Transfer -
In the early stages, nerve branches of other healthy, intact nerves of the face can be transferred to the affected facial nerve. The fibres will grow or regenerate into the affected nerve and supply the muscles of the face.
Free muscle transfer or Gracilis Muscle Transplant
The microsurgeon transplants the gracilis muscle (located in the inner thigh) to replace the facial muscles enabling the patient to smile. The free flap transfer is done with its artery, vein, and nerve to enable movement of the transferred muscle. The muscle is attached to the angle of the mouth, such that contracting it brings about a smile. The patient needs to undergo two stages of this surgery A natural-looking smile is considered as one of the best outcomes of this surgery.
This free tissue transfer involves the transfer of distant nerves and muscle to the paralyzed face to improve facial symmetry by restoring blood supply and muscle movements.
Nerve transfers –
In this procedure, the surgeon reroutes a healthy and functioning nerve (donor nerve) and connects it with a damaged and nonfunctioning nerve (recipient nerve). The nerve fibers of the donor nerve grow within the damaged nerve and it regenerates.
Nerve transfer is an ideal treatment for flaccid facial palsy patients, especially those with severe nerve injuries with zero recoveries of function or discontinuity of the facial nerve. Therefore, nerve transfer is performed only if there is a viable facial musculature and intact neuromuscular junction that is usually within12 months of palsy.
Dr. Leena Jain is one of the most experienced facial palsy surgeons in Borivali, Mumbai who performs eye closure surgery and smile restoration surgery with precision for good outcomes.
Eye Closure Surgery
Facial palsy patients face serious issues of varying degrees of eye closure, including dry eyes and other cosmetic concerns. This condition is referred to as lagophthalmos and is one of the most damaging results of facial Palsy. As a result, there are multiple eyelid surgery options such as insertion of a gold weight in the upper eyelid crease, Palpebral spring placement,etc. The lower eyelid is corrected through a lower eyelid tendon sling, modified tarsorrhaphy, and tarsal wedge resection. These surgeries focus on better closure and optimum protection of the eyes against dryness and corneal ulceration.
A smile is important, and hence its restoration is equally important. The smile restoration procedure depends upon the patient's presentation and the extent of the damage. The most preferred surgery options include cross facial nerve graft and masseteric nerve transfer for smile reanimation. If facial palsy attack is more than two years old, then the most suitable procedures include temporalis tendon transfer (T3) and free muscle transfer with gracilis muscle.
The combination of cross facial nerve graft and masseteric nerve transfer is highly suitable for smile restoration in select patients affected with Facial Palsy.
Dr. Leena Jain suggests a pro-active patient-doctor relationship that helps assess the risks and benefits of possible surgery options to restore the smile and functionality of the affected patient.
The journey of recovery from facial Palsy is long and challenging, and hence extreme patience and faith in the treating surgeon are the key factors for the best possible outcomes.