The facial nerve controls the facial muscles, especially those around the eyes and mouth – for example, the muscles that lift the eyebrows, close the eyelids and raise the corners of the mouth to shape a smile. It is in these areas that patients with facial palsy most commonly experience problems.
Patients with facial palsy experience varying degrees of paralysis in one half of the face – this paralysis can make it difficult to close the eye, raise an eyebrow, whistle or smile.
In some cases symptoms are mild and can be treated with a course of steroids, Botox or other medication. In other cases symptoms are severe and require surgery to restore function and appearance in the affected area.
In this image, the various problems that can arise in left-sided facial palsy are show. The patient cannot raise his left eyebrow and the forehead lacks wrinkles. The upper eyelid does not close fully and the lower eyelid droops away from the eye. The left side of the face droops. He is unable to raise the left side of his mouth and has an asymmetric smile.
What conditions might affect a patient in this area?
Facial palsy can be both congenital and acquired. When acquired, it is most commonly brought on by a condition called Bell’s palsy, which is caused by infection or by a reduced blood supply to the facial nerve. Facial palsy can also be triggered by a tumour or stroke.
What surgery is available, and what techniques are involved?
There are a range of reconstructive surgical operations for the correction of facial palsy. As all cases of the condition vary, each surgical intervention is tailored very specifically to a patient’s needs.
When facial palsy affects the lower eyelid, surgeons can carry out a tendon graft to create a sling which is threaded under the eyelid to provide the necessary support. Sometimes the aperture of the eye is partially closed to ensure that the eye is protected. Cartilage grafts can also be used to augment and support the muscles in the lower eyelid, using cartilage taken from the patient’s ear.
In the upper eyelid, surgeons can insert a small gold weight under the skin and muscle of the affected eyelid to help close the eye. Alternatively, surgeons may opt to lengthen the levator muscle in the middle of the eyelid. In cases where both upper and lower eyelids are affected, a temporalis transfer can be undertaken, whereby surgeons move muscle from the temple to the eyelids to restore strength in this area and counter the effects of paralysis.
When facial palsy affects the mouth, surgeons can conduct similar operations to support and restore muscles. Temporalis muscle transfers and static slings are used to support the atrophied mouth muscles. The temporalis muscle sits on the temple region of the side of the head, its main function is to help close the jaws. When transferred to the face in facial palsy the patient needs to relearn how to move the face by trying to close the jaws. Surprisingly this can readily be learnt and become second nature.
It is also possible to transfer a muscle from another part of the body as a free tissue transfer into the paralysed side of the face. In the first stage a nerve graft is taken from the functioning opposite side of the face, a cross-facial nerve graft. After several months when the nerve endings have grown across the face the muscle transfer operation is done. The blood supply to the muscle is restored by connecting its’ supplying artery and vein to an artery and vein in the face or neck. Its nerve supply is established by connecting its motor nerve to the end of the cross-facial nerve graft. After a period of weeks the muscle will begin to contract in response to normal facial movements. The advantage of this more complex procedure is that it can be possible to restore a spontaneous smile.
What can I expect as a patient?
Patients undergoing surgery for the treatment of facial palsy can expect to be off work for about two weeks, with at least one night spent in hospital following the operation. Most people require several procedures to reverse the paralysis, but again this depends upon the severity of the case and the complexity of the surgery required.
As with all operations, 100% restoration of function or normalisation of appearance can never be guaranteed, but generally reconstructive surgery for the correction of facial palsy is very successful. Around 90% of patients recover from Bell’s palsy, although it can take up to two years before the full results of certain surgical procedures are seen.
Who will I see as a patient?
You will be seen by a multi-disciplinary team. This team will be made up of specialists working together to make sure that the best possible treatment is given. A facial palsy specialist team may include the following:
• Plastic surgeon
• Oral and maxillofacial surgeon
• Opthalmic surgeon
• Speech and Language Therapist
• Ear, Nose and Throat (ENT) specialist
Bell's Palsy Organisation
British Occuloplastic Surgery Society
Facial Palsy UK