Facial Paralysis

Symptoms of facial paralysis may include:

• Unbalanced or asymmetric facial structures
• Inability to raise an eyebrow
• Inability to close an eyelid and protect the eyeball from drying out
• Looseness or sagging of the lower eyelid, leading to tears dripping down the cheek
• Inability to raise, lower or pucker the lips, leading to dribbling when drinking and slurring of some words when speaking

The diagnosis of facial paralysis is often complicated. Facial paralysis may result from a disruption in the part of the brain called the motor cortex, injury to the facial nerve or damage to the muscles that control facial expression.

Diagnosis involves a consultation with a doctor, a complete physical exam and imaging studies of the brain and face. Your doctor may recommend one or more of the following imaging tests:

• Magnetic resonance imaging (MRI) and computed tomography (CT) scan to rule out brain tumors, strokes and infections
• Electromyography (EMG) to evaluate the nerve and muscle

Complications affecting the eye are the most important concerns. The eye is constantly exposed to dry air and must be kept moist. Facial paralysis usually doesn't affect tear production, but it can affect the way the tears are distributed over the eye. There are many ways to prevent the drying effect, including taping, ointments, moisture chambers, patches and even temporary suture-closure of the eyelid.

Potential conditions that are examined before undergoing treatment include:

• Bell's phenomenon, a condition that causes an upward and outward movement of the eye
• Corneal anesthesia, which causes a lack of sensation
• History of dry eye syndrome

To assess the facial nerves affecting the eyes, electromyography (EMG) may be performed.

Treatment of facial paralysis depends on many factors, including the patient's age, cause of the paralysis, severity of paralysis and duration of symptoms. Symmetry of facial features usually can be regained, if the patient participates in facial muscle retraining and therapy. Both are critical for success.

Drs. Knott and Park at UCSF's Facial Plastic and Reconstructive Surgery Clinic treat facial paralysis by transferring muscles and repairing blood vessels and nerves. The treatment is determined after the assessment of symptoms and is tailored to each patient's needs.

Treatment may include one or more of the following approaches:

• Direct Reanastomosis or Nerve Graft — To help restore nerve function, surgeons sew together the severed ends of damaged nerves. If the ends of the nerves can't be sewn together directly, a piece of nerve is harvested and used as a connector or graft between the two ends.
• Eyelid Procedures — Lower-lid tightening procedures and upper-lid weighting operations are used to treat eye conditions. Platinum or gold weights may be implanted under the skin of the upper lid to allow the lid to close passively with gravity. These procedures are usually performed in a clinic or procedure room.
• Temporalis Tendon Transfer (T3) — The temporalis tendon connects the temple to the jaw and can be felt if the temple is lightly touched while clenching the jaw. Transferring the jaw tendon to the corner of the mouth can restore movement to the lips without altering the shape of the face.
• 12-7 or 5-7 Nerve Graft — This procedure connects the hypoglossal nerve, a nerve leading to the tongue, to a facial nerve to produce nerve growth of the facial muscles. This may be performed within the first two years of nerve injury to maintain facial tone, and possibly regain some function. These grafts may also serve as "babysitter" grafts until cross-facial grafting may be performed.
• Contour Restoration — Facial paralysis is sometimes a side effect of serious surgeries and can cause a change in the shape of a patient's face. Fat and tissue transferred from the thigh, a procedure called an anterolateral thigh free flap, are used to restore normal appearance. This type of "flap" is a microvascular reconstruction.
• Botulinum Toxin (Botox) — During treatments to restore nerve function and growth, nerves can grow and branch into an unintended area of the patient's face, causing synkinesis, a combination of voluntary and involuntary muscle movement. For example, if a bundle of nerves designated for lip puckering also grows to the patient's eyelid, unintended eye movement may result during puckering. Some muscles can become hypertonic or overactive as a result of paralysis. Botox injections can be used to treat synkinesis and hypertonic movement by weakening specific muscles and thus restore facial symmetry. Brow ptosis, or a drooping brow, can be treated with botox injections or a brow lift.