Facial Paralysis

The facial nerve is the seventh cranial nerve (CN VII). It begins in the brain and travels through a small canal in the skull alongside the nerve that gives hearing and balance. From there, it passes behind the eardrum and continues through the mastoid bone behind the ear. The nerve then exits the skull under the ear and enters the face passing through the parotid gland (the large saliva gland in the cheek). The nerve then divides into multiple branches that travel under the skin across the face and connect to the muscles responsible for facial movement.

The face contains more than 40 muscles that work together to create expressions. For these muscles to move normally, communication between the brain, the facial nerve, and the muscles must remain intact. Think of it like a lamp: it only works when the outlet, cord, and bulb are all functioning correctly. A problem anywhere along this pathway can lead to facial weakness or paralysis.

Facial paralysis can happen for many different reasons. In general, these causes fall into three main groups: congenital (present at birth), acute (developing suddenly), and chronic (developing slowly over time).

• Congenital Facial Paralysis
  • This type is present at birth and may affect one or both sides of the face. It is linked to conditions that affect how the facial nerve or facial muscles form during development.
• Acute Facial Paralysis
  • Acute paralysis develops quickly, often over hours to a few days. The most common diagnosis is Bell’s palsy, but there are many other causes, including: infections, inflammation, autoimmune conditions, strokes, tumors, or traumatic injuries. This type of paralysis is often most noticeable early on and may improve over time depending on the underlying cause.
• Chronic Facial Paralysis
  • Chronic paralysis develops slowly and often worsens over weeks to months. It may involve only part of the face or the entire half of the face. When facial movement changes gradually over time, tumors or growths affecting the facial nerve are often a concern. These may include benign tumors inside the skull (such as a vestibular schwannoma), parotid gland tumors, or certain skin cancers that affect the nerve. Facial paralysis caused by tumors usually does not improve until the growth is treated. After treatment, some people regain facial movement, while others may continue to experience weakness or paralysis.

Bell’s palsy is the most common diagnosis of facial paralysis . Bell’s palsy is considered a diagnosis of exclusion, meaning all other causes should be reasonably ruled out. The weakness comes on relatively quickly and usually affects one entire side of the face. Some people with Bell’s palsy can move their facial muscles a little bit while others cannot move their muscles at all. With paralysis there may be associated pain in the ear, sensitivity to loud noises, changes in taste, numbness on the same side of the face, or changes in tear production. In addition to lack of facial expression, people with Bell’s palsy can also have difficulty with speech, eating, eye closure and breathing through their nose.

Sudden facial weakness can be alarming, and many people initially worry they are having a stroke. Anyone suffering from acute facial paralysis should seek immediate medical attention to identify the cause of the paralysis and begin treatment. The exact cause of paralysis in Bell’s palsy is not known, but it is thought to be related to swelling of the facial nerve due to a viral infection as it passes through a very narrow opening in the bone on its way from the brain to the facial muscles. The most effective treatment for Bell’s palsy is a course of steroids to counteract the swelling and inflammation around the nerve. There may also be a benefit from antiviral medication in addition to steroids. It is very important that individuals who cannot fully close their eye start using eye lubrication treatment to prevent dryness from damaging the eye.

For most people the facial movement begins to return within a few weeks of paralysis, but a minority of people do not see return of function begin for several months. Fortunately, a large majority of people will return to normal or near normal facial function following Bell’s palsy, but up to 30% of people will not full recover. Once facial movement begins to return, personalized facial massage and retraining exercises with a physical therapist may help improve outcomes. Incomplete recovery from facial paralysis can include decreased movements, abnormal tightness, involuntary movements (synkinesis ), or spasms. There may be nonsurgical and surgical treatment options for those patients who do not fully recover.

Understanding the cause of facial paralysis is the first step in deciding the best treatment. In some cases, the facial movement may improve on its own with time. In other situations, weakness may not improve on its own and treatment may be time sensitive. Treatment options may include medications, physical therapy, minimally invasive injections, or surgery. Treatment is always individualized to the patient’s needs and the specifics of their condition. 

Facial paralysis can impact many aspects of a person’s daily life, from appearance and facial expression to speech, eating, and emotional well-being. That is why treatment goals focus on restoring as much facial symmetry and function as possible. The goal is to help patients regain confidence and live a normal life without the physical or social challenges that can come with facial paralysis.

Facial synkinesis is an involuntary movement that happens when you are trying to make a voluntary facial expression, such as smiling. It can develop as the facial nerve heals after an injury.

As the nerve regenerates, some fibers may reconnect to the wrong muscles. When this happens, a signal meant for one muscle is unintentionally sent to others. For example, when you smile, your eye on the affected side may close. Or when you gently close your eyes, the corner of your mouth may lift.

Think of it like crossed telephone wires – one message is sent, but multiple lines pick it up. There are many treatment options for synkinesis, including facial rehabilitation and chemodenervation injections.

• Nerve Grafting & Repair
  
  • For certain facial nerve injuries from trauma or surgery when the nerve has been cut, directly suturing the nerve back together offers the best option for restoring spontaneous facial movement. Sometimes a nerve graft may have to be used to re-connect the two ends of the nerve. Common donor nerves include the great auricular nerve from the neck (providing earlobe sensation) or the sural nerve from the lower leg (providing sensation to the top of the foot). Best results occur when repair is performed as soon as possible after the injury. After this type of injury and repair, the nerve generally takes at least 6-12 months to heal and start functioning again.
• Nerve Transfer
  
  • In some cases, the facial nerve cannot be repaired directly. In these situations, surgeons can use a different nearby nerve and connect it to the facial nerve to help restore movement. This is similar to a table lamp whose power cord has been cut – by connecting it to a different power source, the lamp can work again. This type of surgery can be time sensitive as the facial muscles can become severely weakened if not repaired in a timely fashion.
  • The most common nerves used for transfers:
    
    • Cross Facial Nerve Graft: A nerve graft is connected to a facial nerve branch on the non-paralyzed side of your face and connects it to a facial nerve branch on the paralyzed side of your face. This can be used to restore spontaneous movement, most commonly the smile on the paralyzed side of your face. This means you will smile automatically when you feel happy, not just when you think about trying to smile.
      
      
    • Hypoglossal to Facial Nerve (12 to 7) Transfer: This procedure redirects a portion of a nerve that normally controls part of your tongue (the hypoglossal nerve) to help power your facial muscles. This procedure can restore resting facial symmetry to the paralyzed side (also known as tone) but is not generally as reliable at producing dynamic movement. There is typically minimal, it any, long term tongue changes from this procedure.
      
      
    • Masseteric to Facial Nerve (5 to 7) Transfer: This procedure redirects a portion of the masseteric nerve normally going to a chewing muscle called your masseter muscle. The surgeon connects the masseteric nerve directly to branches of your facial nerve, allowing the chewing nerve to “take over” and help restore movement to your face. This procedure is reliable in restoring dynamic motion, usually the ability to smile, by allowing the patient to produce the desired movement while clenching their teeth or biting down. Over time, many patients learn to activate it so subtly that it becomes nearly automatic. There are usually minimal, if any, long-term issues with chewing after this procedure.

These procedures are often used in combination to produce the best results. All nerve transfer procedures require at least six months for nerve healing and patient retraining to optimize results.

Selective Neurectomy

• When the facial nerve heals after an injury, it occasionally heals in a slightly abnormal way, leading to tightness or involuntary movements called synkinesis. An example of this is your eye closing when you smile, or your mouth pulling when you blink. A selective neurectomy is a surgery where your surgeon carefully identifies and removes specific nerve branches that are contributing to these unwanted movements. Your surgeon will test each nerve branch to see what it does, and then only removes the ones causing problematic movements, while preserving the nerves that help you smile and move your face normally. This procedure can improve facial symmetry and movement in appropriate patients.

Hypoglossal to Facial (12 to 7) Nerve Transfer

• This procedure redirects a portion of a nerve that normally controls part of your tongue (the hypoglossal nerve) to help power our facial muscles. This procedure can restore resting facial symmetry to the paralyzed side (also known as tone) but is not generally as reliable at producing dynamic movement. There is usually minimal, if any, long-term tongue weakness from this procedure.

Temporalis Tendon Transfer

• The temporalis muscle is a chewing muscle located on the side of your head. In this procedure, your surgeon will detach a portion of the muscle from where it normally attaches on your jawbone and reposition it to the corner of your mouth. This can improve resting symmetry of the face and occasionally allow for patients to be able to subtly move the corner of their mouth when gently biting down or clenching their teeth.

Fascia Lata Facial Suspension

• Tensor fascia lata is strong, tissue from your outer thigh. In this procedure, your surgeon carefully removes a strip of this fascia lata through an incision on your outer leg. They then use this tissue to support or suspend certain droopy areas of the face such as, the corner of your mouth, cheek, or lower eyelid. This provides immediate improvement in facial symmetry at rest and helps with functions like eating, drinking, and speaking. This procedure does not provide additional ability to create volitional movements. This surgery is particularly useful for patients who may not be candidates for more complex muscle transfer surgeries.

Asymmetric Facial Reconstruction or Facelift

• Facial paralysis can cause the two sides of your face to age at different rates which can create asymmetry of your face and neck over time. This can be addressed by performing a face or neck lift on one side. This procedure lifts and repositions the deeper tissues of your face (not just the skin to restore symmetry. Your surgeon may combine this with other procedures if appropriate.

Platysma Myectomy

• The platysma is a thin muscle that extends from your lower face, across the neck and into the upper chest area. Sometimes this muscle can become too tight and dysfunctional after the facial nerve is injured. In this procedure, your surgeon removes a strip of this muscle which can improve tightness and appearance. This procedure can be performed alone or in combination with other procedures when appropriate.

Eyebrow Lift

• Facial paralysis can sometimes cause asymmetry of your eyebrows. This occasionally leads to visual obstruction. An eyebrow lift re-positions the eyebrows to a more anatomically correct or symmetric position. There are several different ways to perform an eyebrow lift, and the specific technique depends on your age, hairline, and goals. Your specific surgical technique will be discussed at your pre-operative appointment. The procedure can improve vision, reduce forehead heaviness, and restore facial balance.

Lip Lift 

• Facial paralysis can cause asymmetry of your upper lip. In certain cases, the upper lip may droop or be less visible than the unaffected side. A lip lift procedure addresses this by removing a small portion of tissue from under your nose and repositioning the lip to an more anatomic and symmetric position. Patients typically experience immediate improvement in lip position and function.

Depressor Anguli Oris (DAO) Myectomy

• The depressor anguli oris (DAO) is a small muscle at the corner of your mouth that normally pulls your lip downward. When an injury to the facial nerve occurs, this muscle can become overactive and tight on the affected side, pulling your mouth down incorrectly and preventing you from smiling effectively. DAO excision is a surgery where your surgeon removes a portion of this overactive muscle through a small incision inside your mouth or on your chin. This often improves tightness of the face and the overall symmetry of your smile. This is a relatively quick, low-risk procedure that often provides immediate improvement in smile symmetry, facial tugging with smiling, and overall quality of life.

Masseteric to Facial (5 to 7) Nerve Transfer

• This procedure redirects a portion of the masseteric nerve, normally going to a chewing muscle called the masseter muscle, to the facial neve. Your surgeon connects the masseteric nerve directly to branches of your facial nerve, allowing the chewing nerve to “take over” and help restore movement to your face. This procedure is reliable in restoring dynamic motion, usually the ability to smile, by allowing the patient to produce the desired movement while clenching their teeth or biting down. Over time many patients learn to active it so subtly that it becomes nearly automatic. There is usually minimal, if any long-term issue with chewing after this procedure.

Cross-Facial Nerve Grafts

• A nerve graft is connected to a facial nerve branch on the non-paralyzed side of your face and connects it to a facial nerve branch on the paralyzed side of your face. This can be used to restore spontaneous movement, most commonly the smile, on the paralyzed side of your face. This means you will smile automatically when you feel happy, not just when you think about trying to smile.

Temporalis Tendon Transfer

• The temporalis muscle is a chewing muscle located on the side of your head above your ear. In this procedure, your surgeon will detach a portion of the muscle from where it normally attaches on your jawbone and reposition it to the corner of your mouth. This can improve resting symmetry of the face and occasionally allow for the patients to be able to subtly move the corner of their mouth when gently biting down or clenching their teeth.

Gracilis Free Muscle Transfer

• The gracilis is a small, thin muscle from your inner thigh. Your surgeon can transplant this muscle from your thigh along with its blood vessels and nerve supply to your face to “rebuild a new smile muscle.” Your surgeon then re-connects the blood vessels and nerves to your existing anatomy to allow you to activate this new muscle and use it to smile. The most common nerves used to power a gracilis muscle is a cross-facial nerve graft and/ or the masseteric nerve (as described above). After the nerves heal (at least 6-12 months), you will start to notice movement restored to the paralyzed side of your face.

Upper Eyelid Weight Placement

• Sometimes facial paralysis prevents your upper eyelid from closing properly. In these situations, a small weight (usually made of platinum or gold) can be implanted to aid in fully closing your eye while still allowing you to open your eye. The weight helps to protect your cornea from drying out and helps prevent long-term eye damage. Most patients achieve complete or near complete eye closure after this procedure.

Lateral Tarsal Strip / lower eyelid tightening

• Facial paralysis can cause your lower eyelid to droop away from your eye (called ectropion). This procedure is performed through a small incision at the outer corner of your eye to tighten and lifts your lower eyelid in an improved position. This helps protect your eye and improve tear drainage. It is a relatively quick surgery and can be performed as a stand alone or in combination with other procedures if appropriate.

Bipedicled Orbicularis Oculi Myocutaneous (BOOM) Flap

• Facial paralysis can sometimes cause drooping of the lower eyelid. The BOOM flap uses a strip of healthy skin and muscle from your upper eyelid that is transferred to your lower eyelid to help support and pull up on the lower eyelid. This strip remains attached at both the inner and outer corners of your eye to maintain its blood supply and support. This is often performed after other eyelid procedures have been attempted prior.

Modified Hughes Flap for lower eyelid tightening

• Facial paralysis can sometimes cause drooping of the lower eyelid. The modified Hughes flap is a procedure in which your surgeon creates a flap from the inside corner of your upper eyelid to connect it to the lower eyelid. This helps hold the lower eyelid in a higher position while not obstructing your vision. This procedure helps protect your cornea and reduce dryness and tearing

Fascia Lata Facial Suspension

Facial paralysis can cause weakness to the muscle around the nose, leading to blocked nasal airflow. Tensor fascia lata is strong, natural tissue from your outer thigh. In this procedure, your surgeon carefully removes a strip of this tissue from your thigh and uses it to support or suspend certain droopy areas of the face such as the nose, corner of your mouth, cheek, or lower eyelid. This provides immediate improvement in facial symmetry at rest and helps with functions like breathing through your nose, eating, drinking, and speaking. This procedure does not provide additional ability to create volitional movements.

Septorhinoplasty

Facial paralysis can cause weakness of the muscles around the nose leading to blocked nasal airflow. A septorhinoplasty straightens the nasal septum and strengthened other parts of your nose with cartilage grafts to improve breathing through your nose. This is a comprehensive approach that addresses both the structural and functional problems that contribute to breathing difficulties in facial paralysis patients.

In some cases of facial paralysis, starting treatment early may help improve recovery. These treatments depend on the cause of the facial paralysis and can include medications such as antibiotics, antivirals, and steroids. For patients diagnosed with Bell’s Palsy, research shows that treatment with steroids and antiviral medication within 72 hours of onset likely improves recovery time and chances of full recovery. However, not all causes of facial paralysis benefit from medication, which is why it is important to undergo evaluation as soon as paralysis develops.

There are two main types of in-office injections used to help people with facial paralysis; these are chemodenervation with botulinum toxin and injectable filler. Both work in different ways and may be used together to help optimize facial function.

Chemodenervation with Botulinum Toxin

Botulinum tox is a well-studied and overall safe medication that has been used for years for many cosmetic and medical concerns. This medication works by temporarily weakening the muscle it is injected into. For the treatment of facial paralysis, very small doses are injected into muscles in the face primarily to help decrease excess muscle tightness, improve facial symmetry, and decrease other unwanted facial movements (synkinesis). By selectively weakening muscles that are overactive the function and balance of the face can be improved.

The injections are easily performed in the office with only minor discomfort. The results take one to two weeks to reach full effect and wear off after approximately three months. Repeat treatments are very effective and safe for years if needed. Patients have the best results when they combine botulinum toxin injections with facial retraining exercises. Generally, we are successful at getting botulinum toxin injections covered by your insurance plan.

For someone seeking a more permanent solution, a selective neurectomy may be an option.

Facial Filler 

Injectable filler comes in many forms. It helps restore volume to various parts of the face and has been used for years in both cosmetic and reconstructive applications. Filler can be used in patients with facial paralysis to help restore facial symmetry and decrease liquid that may spill from the corner of the mouth.

Facial filler treatment is easily performed in the office with topical anesthesia and minimal discomfort. The effects of the injections are immediate, and most fillers will last between six months to two years.

Please note that when fillers are used to improve facial symmetry in patients with facial paralysis, they are not covered by insurance and are considered an out-of-pocket expense.

Physical therapy plays an important role in the evaluation and treatment of facial paralysis. Facial retraining is a distinct area of practice within physical therapy, guided by clinicians with focused training in facial nerve rehabilitation to support improved facial movement and function. This approach relies on active participation and consistent practice to promote meaningful, long-term improvement.

Treatment focuses on improving facial movement, coordination, and comfort while addressing symptoms such as weakness, asymmetry, muscle tightness, involuntary movements (synkinesis), pain, fatigue, difficulty with facial expressions, speech, eating, and eye protection. Sessions may include gentle facial massage and relaxation techniques to reduce muscle tension, along with targeted exercises designed to restore movement and symmetry.

Because normal facial expressions are small and subtle, retraining emphasizes precise, controlled movement to promote healthy nerve-to-muscle communication and reduce maladaptive movement patterns. Visual feedback, such as mirror therapy, is often used to help patients recognize, refine, and balance facial movements on both sides of the face.

Education and self-management strategies are an essential part of therapy, empowering patients to continue progress outside of the clinic and throughout recovery. By combining evidence-based techniques with individualized care, physical therapy supports both functional recovery and quality of life, helping patients regain confidence, comfort, and control in everyday facial movements.

Facial paralysis affects the ability to move the lips and cheeks which have an impact on an individual’s ability to speak and eat. Assessment by a speech and language pathologist can identify specific difficulties for each person and may offer compensation strategies to help with these important functions. Assessments can also be helpful to follow an individual after treatment or during recovery to track improvement.

Biobehavioral medicine recognizes that recovery from facial paralysis involves more than nerve and muscle healing alone. It focuses on the connection between biological factors (such as nerve injury, muscle function, and healing), psychological factors (including emotional health, stress, and self-image), and behavioral factors (movement patterns, habits, and social interaction).

Facial paralysis can affect how a person eats, speaks, expresses emotion, and connects with others. These changes may also influence confidence, mental well-being, and daily behavior. Stress, anxiety, or altered movement patterns can, in turn, impact muscle tension, coordination, and overall recovery.

By incorporating a biobehavioral therapy approach into our treatment model, our care addresses both physical function and quality of life. Treatment may include education on stress and muscle awareness and strategies that support emotional resilience and long-term recovery. This comprehensive model allows us to treat the whole person, not just the facial nerve injury - resulting in more effective, compassionate, and sustainable care.

It is common that patients with facial paralysis also experience balance problems. MUSC’s dedicated Balance Center  provides specialized evaluation and therapy to address dizziness, imbalance, and difficulty with coordination.

Our team works in a multidisciplinary manner, collaborating closely with neurology, otolaryngology, neurosurgery, and rehabilitation specialists to create a personalized treatment plan. The goal of balance therapy is to improve stability, reduce dizziness, and help you feel confident and safe in your daily activities.