It had been 27 years since the woman had smiled normally.
Explore This IssueNovember 2020
Her face had drooped more than two decades ago, and although many cases of facial palsy resolve spontaneously, hers didn’t. Her face twisted, limiting her expression, affecting nearly every aspect of her life. Previous treatment attempts hadn’t helped.
She had a little hope left, though, and scheduled an appointment with Kofi Boahene, MD, professor of otolaryngology–head and neck surgery at Johns Hopkins Medicine in Baltimore, after reading an article about his success with smile restoration and facial reanimation. Minutes into her appointment, Dr. Boahene told her, “I think we can help you.” Tears of relief and joy flowed.
“There’s a solution for almost everyone,” Dr. Boahene said.
But that wasn’t the case just a decade ago. Those who developed Bell’s palsy, the most common form of facial palsy, and didn’t recover completely were often left with lingering paralysis and, in many cases, synkinesis, or unwanted contraction of facial muscles during attempted movement. Other causes of facial palsy (acoustic neuroma, trauma, neoplasms of the parotid gland) also often result in long-term physical and psychological complications and have had few effective treatment options. Today, however, physicians can help most patients regain their smiles and facial movement.
“The field of facial reanimation may have changed more in the past decade than any other sub-specialty within otolaryngology–head and neck surgery, certainly within facial plastic surgery,” said Patrick Byrne, MD, MBA, chair of the Cleveland Clinic Head and Neck Institute in Cleveland, Ohio. “Now, virtually everybody with either incomplete or complete facial paralysis has treatment options that can help them improve.”
Making an Accurate Diagnosis
When patients first notice their faces drooping or failing to respond as usual, they often assume they’re having a stroke and call 911 or head to a local emergency department. When testing rules out a stroke, patients may be instructed to follow up with their primary care physician.
If the paralysis is restricted to one side of the face, the patient may have idiopathic facial palsy, or Bell’s palsy. According to the National Institute of Neurological Disorders and Stroke, more than 40,000 Americans are diagnosed with Bell’s palsy each year, and most—three out of four—improve without treatment.
The field of facial reanimation may have changed more in the past decade than any other sub-specialty within otolaryngology–head and neck surgery, certainly within facial plastic surgery. —Patrick Byrne, MD, MBA
Not all cases of facial paralysis are Bell’s palsy, however, and careful diagnosis allows patients to access effective treatment in a timely manner. A detailed history is crucial for accurate diagnosis, as symptom timing and progression are important differentiators between Bell’s palsy and other causes of facial paralysis. Bell’s palsy occurs suddenly and unilaterally and involves every zone of the affected side of the face. Symptoms should “be as bad as they’re going to get” within 72 hours of onset, said Caroline Banks, MD, a facial plastic and reconstructive surgeon specializing in facial nerve surgery at Massachusetts Eye and Ear Infirmary in Boston. If the patient reports continued evolution in symptoms over a period of weeks or months, they do not have Bell’s palsy. Additionally, patients who present with systemic symptoms, such as fever, body rash, severe fatigue, headache, vertigo, and hearing loss, probably don’t have Bell’s palsy.
If you practice in an area where Lyme disease is endemic, as Dr. Banks does, it makes sense to order a blood draw and test for Lyme disease. Otherwise, blood work is unnecessary. Palpation may help uncover other possible causes of facial paralysis, including tumors in the parotid gland; medical imaging may be a good idea if it’s unlikely that the patient has Bell’s palsy and you cannot palpate a tumor, as CTs and MRIs can uncover small tumors. You may also want to ask the patient if they’ve ever had a skin cancer, pre-cancer, or growth removed from their face, Dr. Boahene said. If so, it’s possible the cancerous cells have invaded nerves supplying the face, and exploratory surgery may be warranted.
Some centers will offer electrodiagnostic testing for patients who present within two weeks of the onset of symptoms. Patients who do poorly on both electroneuronography and electromyography may be candidates for facial nerve decompression; however, this surgery is controversial among facial nerve surgeons, and many patients aren’t good candidates, either because they don’t fit the electrodiagnostic criteria, they don’t seek specialist care within that two-week window, or they aren’t interested in facial nerve decompression, Dr. Banks said.
“In general, electrophysiologic testing isn’t necessary unless you want to act on the result of the test,” Dr. Boahene added. “Also, if somebody’s weakness isn’t complete—there’s still a little bit of movement—there’s no need to do these tests.”
Bell’s Palsy and Facial Paralysis Management
Patients who have Bell’s palsy should receive oral corticosteroids within 72 hours of symptom appearance (unless the patient has contraindications to steroid treatment). Early treatment with prednisolone increases the chance of complete recovery of facial function to 82% (Aust Prescr. 2017;40:94-97). After 72 hours, “the benefit is a toss-up,” Dr. Boahene said, “but if you were to err one way or the other, I would suggest you give it.”
Many clinicians also prescribe antiviral agents, as the latest Cochrane review notes “a significant difference in long-term sequelae in favor of antivirals plus corticosteroids” in patients with severe Bell’s palsy (Sao Paulo Med J. 2015;133:383).
Patients who show signs of recovery within six weeks have a good prognosis, Dr. Boahene said. However, it’s important to warn patients about the possibility of synkinesis. To minimize the likelihood of the development of unwanted facial movement, Dr. Boahene recommends facial retraining exercises “as soon as the face is recovering.”
If a patient … hasn’t smiled properly in 10 years, I’ll inject lidocaine into specific tight muscles … and then show them their improved smile. If they like the results, I say, ‘Okay, then we want to do surgery to replicate what the lidocaine did. —Kofi Boahene, MD
Facial retraining—essentially, physical therapy for the face—is one of the major recent advancements in the treatment of facial palsy, Dr. Byrne said. “We’ve learned that a highly trained physical therapist who knows how to help patients with facial paralysis can provide a lot of benefit.”
Therapists teach patients how to consciously relax muscles that want to pull tight, allowing patients to gain more control of their facial expressions and, perhaps, avoid synkinesis. A 2011 Cochrane review concluded that “there is no high-quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low-quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases,” while other studies suggest that “early facial exercise may reduce recovery time, long-term paralysis, and number of chronic cases” (Cochrane Database Syst Rev. 2011; doi: 10.1002/14651858.cd006283.pub3; Aust Prescr. 2017;40:94-97).
“We believe that focused facial nerve physical therapy can improve function in patients with facial paralysis,” Dr. Banks said, although she did add that it’s difficult to study whether seeing a physical therapist early on will improve outcomes overall and prevent synkinesis. Unfortunately, it can be difficult for patients to access facial retraining; while it is available at some academic medical centers, it’s highly specialized and not readily accessible in most communities. As the healthcare system continues to move toward virtual visits, facial retraining may become a realistic option for more patients.
Another treatment option is the injection of neuromodulators, including Botox. “Over the past 20 years, we’ve learned a lot about how we can use these to help with facial dysfunction, symmetry, and balance,” Dr. Byrne said. Targeted Botox injections can weaken the muscles that are pulling in a direction that isn’t in favor of relaxed facial movement. The specific injection locations will vary from patient to patient, depending on their presentation. Muscles that are frequently targeted include the platysma and the depressor anguli oris.
Botox injection can complement facial retraining. “Sometimes, it takes too much patient effort to suppress unwanted movement in the face,” Dr. Boahene said. “If you use Botox to help them out, they can put their effort into the movement they want, and then over time the brain picks up this new pattern of movement and you don’t need to keep repeating the Botox.”
Some patients return to baseline after the Botox wears off, however. Physicians can repeat the injection, but if the face once again returns to its unwanted baseline, it’s time to consider surgical options.
There are a number of surgical options for improving facial function that can make a difference for patients:
Selective Myectomy. One option is to surgically target the muscles that are causing unwanted facial movement or restricting the smile. If weakening the muscles with botulinum toxin improves facial function and symmetry, this temporary result can be made permanent by cutting specific facial muscles. “You can cut some of the lower lip muscles to either release the smile or balance the lower lip. You can also cut the platysma muscle if it’s causing banding or discomfort in the neck,” Dr. Banks said. “Myectomies are something you can do in the procedure room under local anesthesia in about 20 to 30 minutes.”
Dr. Boahene also likes to use selective myectomy to treat patients. “If a patient who comes to my office hasn’t smiled properly in 10 years, I’ll inject lidocaine into specific tight muscles to relax them and then show them their improved smile. If they like the results, I say, ‘Okay, then we want to do surgery to replicate what the lidocaine did,’” he said. Final results are usually apparent a week or two after surgery.
“Surgery can be life-changing,” Dr. Boahene said. “Patients often cannot believe that it took all of these years to be offered a solution.”
Selective Neurectomy. Another alternative is selective neurectomy, a technique pioneered and popularized by Babak Azizzadeh, MD, chairman and director of The Center for Advanced Facial Surgery in Beverly Hills. During this procedure, the surgeon opens the face and identifies and electrically stimulates nerve branches going to the smile and lower face. If stimulation of a specific nerve results in unwanted movement, cutting that nerve can eliminate undesirable motions and allow other nerves to grow stronger. A 2019 selective review of 63 patients who underwent modified selective neurectomy for post-facial paralysis synkinesis noted statistically significant improvement in facial function and improved smile scores. No serious complications were reported. Seven patients (11/63) reported temporary oral incompetence postoperatively, and the revision rate was 17% (Plast Reconstr Surg. 2019;143:1483-1496).
“We’ve realized that much of the dysfunction that lingers after Bell’s palsy is because a lot of nerves start firing all at once. It isn’t so much that they’re weak as they’re all pulling against each other,” Dr. Byrne said. “We can unlock the face by selectively weakening some nerves and allowing the other ones to take over and achieve more symmetry in the smile, for instance.”
Despite the effectiveness and increasing popularity of selective neurectomy as an option for many patients, Dr. Boahene said it isn’t his first option. “It’s more involved,” he said. “You have to expose all the facial nerves and go from one nerve to the other, testing them to identify the right nerves for neurolysis.” He prefers to perform selective myectomy first, if feasible.
Gracilis Smile Restoration. If either selective myectomy or neurectomy does not produce a pleasing result, surgical muscle transfer is another possible solution. The gracilis muscle can be transplanted from the leg to the face; however, the surgery is involved. Patients typically stay in the hospital for three days, and it usually takes months to see the final effect.
Refinements to the gracilis muscle transfer procedure have produced exciting results in recent years. “We can now use a smaller muscle, the omohyoid muscle, and introduce more nerve input,” Dr. Byrne said. “We can split the muscle into multiple vectors. There’s been an iterative process of these procedures, and now we can apply it to a vastly greater number of patients, including those who weren’t even considered before.”
Patients get better results as well. Previously, patients who underwent gracilis muscle transfer often regained movement but not their natural smiles. “The smile you get looks like a Mona Lisa smile,” Dr. Boahene said. “You don’t see teeth, and their face looks lopsided because we put a big muscle in their face.”
Myectomies are something you can do in the procedure room under local anesthesia in about 20 to 30 minutes. —Caroline Banks, MD
By dividing the muscle and transplanting it along multiple vectors, surgeons can help patients achieve a natural smile. “We actually take that one muscle and tease it out into multiple bundles that will move the face in different directions,” Dr. Boahene said. “They can get very close to a normal smile, and that’s a big development in the past four or five years.”
According to a 2018 JAMA Facial Plastic Surgery article, the multivector surgical approach resulted in “statistically significant improvement in the dental display, smile width, and correction of paralytic labial drape.” Four of 12 patients also regained “dynamic wrinkling of the periorbital area with smiling” (JAMA Facial Plast Surg, 2018; doi: 10.1001/jamafacial.2018.0048).
5-to-7 Nerve Transfer. Another option for facial reanimation is 5-to-7 nerve transfer (masseteric- or deep temporal-to-facial nerve transfer). This surgery may be a good choice for patients who experience facial paralysis because of acoustic neuroma or a severed nerve. It’s a time-sensitive surgery that should only be attempted if it has been less than two years since the onset of facial paralysis, as the muscles of the face must still be healthy.
“The sooner you do it, the better,” Dr. Banks said. “We say ‘up to two years,’ but if you can get it done in a year or six months, you’ll have a better result.” A 2019 study reported that 5-to-7 nerve transfer can significantly improve quality of life for patients with flaccid facial paralysis; however, just 20% of patients with postparalysis facial palsy experienced benefits (Plast Reconstr Surg. 2019;143:1060e-1071e. doi: 10.1097/PRS.0000000000005591).
The smile is an important part of human communication. Thanks to advances in management of facial palsy, specialist head and neck surgeons can now help most patients regain their smiles.
Jennifer Fink is a freelance medical writer based in Wisconsin.