Facial Nerve Centers and New Treatment Options Can Make a Difference for Patients with Facial Paralysis

Facial paralysis, whether it’s caused by a virus, tumor, trauma, or congenital abnormality, can be devastating to patients and significantly impact their quality of life. New and refined treatments and specialized facial nerve centers, however, can make a big difference in restoring smiles and more.

“Treating patients with facial paralysis is one of the best parts of my practice; it makes a dramatic impact on their lives,” said Myriam Loyo Li, MD, MCR, co-director of the Facial Nerve Center at the Oregon Health & Science University in Portland. “As they gain facial strength, we get to watch them feel more confident in their appearance. Knowing the treatment I provided helped make this happen is incredibly rewarding.”

The list of things that can cause facial paralysis is extensive, ranging from viruses to traumas to cancers. A diagnosis of Bell’s palsy is often one of exclusion. —Irene A. Kim, MD

Even in cases that a physician may consider minor, facial paralysis can be very disturbing to a patient. Irene A. Kim, MD, a facial plastic and reconstructive surgeon, an assistant professor in the department of head and neck surgery, and director of the Facial Nerve Center in the David Geffen School of Medicine at the University of California, Los Angeles, said that many patients have told her they portray a perpetually angry, sad, or upset demeanor to their family and friends. Others feel that they scare their grandchildren, and some patients have had difficulty finding work or going on dates. “As physicians, it’s important to be aware of this and to be sensitive and compassionate to patient needs,” she said.

Bell’s Palsy or Not?

Bell’s palsy is the most common cause of facial paralysis, according to the National Institute of Neurological Disorders and Stroke; about 40,000 people in the United States experience the condition each year. Possible triggers may include viral infection, impaired immunity, infection causing inflammation in a facial nerve, and myelin sheath damage. However, it’s not always clear cut.

“The list of things that can cause facial paralysis is extensive, ranging from viruses to traumas to cancers. A diagnosis of Bell’s palsy is often one of exclusion,” said Dr. Kim, who is board certified in otolaryngology and fellowship trained in facial reanimation surgery for facial paralysis.

With an accurate diagnosis of Bell’s palsy, according to Dr. Kim, treatment can include high-dose steroids and antiviral medications such as acyclovir and valacyclovir. Although supportive evidence may not exist for other measures, she routinely discusses the following strategies with her patients: Reduce stress, eat a well-balanced diet, avoid highly inflammatory foods, and consider acupuncture.

“Some patients are eager to participate in proactive measures while they anxiously await the return of facial function and these holistic measures could help patients feel less anxious and like they have some control of their situation,” says Dr. Kim. She prefers that patients avoid using any over-the-counter energy tools that actively stimulate facial nerves or muscles, and, based on her own patients’ experiences, wonders if these could be related to stronger synkinesis in the future.

There are several misconceptions about Bell’s palsy. The first is that it can include facial paralysis with slow onset. “Facial paralysis is a manifestation of many different diagnoses. While Bell’s palsy is the most common cause of facial paralysis, patients are frequently misdiagnosed as having Bell’s palsy,” said Matthew Q. Miller, MD, director of the University of North Carolina Facial Nerve Center in Chapel Hill. “Bell’s palsy and Ramsay Hunt Syndrome—both of which are caused by virus reactivation affecting the facial nerve—are always associated with sudden onset (within 72 hours) facial paralysis. Gradual onset facial paralysis is never Bell’s palsy. Gradual onset facial paralysis can be a sign of either a benign or malignant tumor, or another less common cause of facial paralysis. It is very important patients are evaluated by a provider familiar with facial paralysis to make sure the correct diagnosis is made, and appropriate treatment initiated.”

Kofi Boahene, MD, a professor of otolaryngology at Johns Hopkins Medicine in Baltimore who specializes in facial reanimation surgery, had a case like this. A patient who had facial paralysis that came on slowly was diagnosed with Bell’s palsy. It hadn’t improved for three years, and each year the patient had had an MRI that showed no abnormalities.

“It’s important to make sure the history the patient gives matches Bell’s palsy, which happens in the course of hours to days,” Dr. Boahene said. “If it takes months, that isn’t Bell’s palsy. Even if the MRI is normal, that still isn’t Bell’s palsy, and you need to go and look for a different cause.” For this particular patient, Dr. Boahene did exploratory surgery and found thickening in a facial nerve. The pathology of the nerve came back as a squamous cell carcinoma; the patient received immunotherapy.

Several new advances have been made in helping patients who may have had an unsatisfactory recovery. “Over the past two decades, microsurgical free tissue transfer utilizing the gracilis free flap has become extensively used for patients with complete paralysis and Moebius syndrome,” said Babak Azizzadeh, MD, chairman and director of the CENTER for Advanced Facial Plastic Surgery in Beverly Hills, California. The other two surgical techniques that have also improved our treatment for facial paralysis include orthodromic temporalis tendon transfer and masseteric facial nerve transfer in combination with hypoglossal nerve transfer. The utilization of neuromuscular retraining and nerve modulation has also improved due to better technical administration.” 

“Treatment for patients with facial paralysis has experienced a renaissance the last decade,” added Dr. Miller. “There has especially been an explosion in treatment options for patients with chronic Bell’s palsy, chronic Ramsay Hunt Syndrome, and other causes of nonflaccid facial paralysis. In nonflaccid facial paralysis, for instance, as the facial nerve recovers from an acute in-continuity nerve insult, it can regenerate to both appropriate and inappropriate facial muscles. This ‘aberrant facial nerve regeneration’ creates an imbalance in facial muscles; if the smile antagonist muscles (e.g., depressor anguli oris, buccinator) become stronger than a patient’s smile muscles (e.g., zygomaticus muscles), then a patient can be left with significant smile asymmetry, preventing them from showing they are happy. We now have procedures such as selective denervation surgery and depressor anguli oris excision that can rebalance the facial muscles and help patients smile again.”

In addition to facial paralysis resulting from cancer and cancer surgeries, rarer causes of facial paralysis may include Moebius syndrome and Lyme disease, according to Dr. Kim. “With regard to Moebius syndrome, if babies are born with facial paralysis, we can perform surgery on them when they are older. We typically take a portion of the gracilis muscle that comes with an artery, a vein, and a nerve, and transplant this into the face,” she said. “We transfer the masseteric nerve into it or borrow a nerve from the other side of the face if they have a functional one. Over time, the nerve grows into the muscle and helps the child smile.”

Because facial strength can take a long time to return following the onset of Bell’s palsy or a surgical intervention, Dr. Kim keeps visual records (photos and videos) of her patients from each visit. Patients will sometimes be surprised at the progress they hadn’t even noticed, and perhaps feel hopeful for further improvement.

Unfortunately, patients with facial paralysis frequently see providers who tell them, “There’s nothing we can do,” or “It isn’t that bad; others have it worse,” noted Dr. Miller. “Facial paralysis has a strong association with depression, anxiety, and social withdrawal, and these statements make these mental health issues worse,” he explained. “They not only create a feeling of hopelessness, but they can also make patients feel bad about seeking treatment. No matter how long a patient has had facial paralysis and what caused their paralysis, there are always treatment options. I just performed selective denervation surgery on someone who had facial paralysis for almost 50 years, and they had a great result!”

Facial Nerve Centers

Multidisciplinary facial nerve centers, which can be found in several major U.S. cities, have the advantage of practitioners with a variety of perspectives and often customized care for patients.

“The management of facial palsy is complex and requires a team of individuals with different specialties, which includes a facial plastic surgeon, neurologist, neurosurgeon, neuromuscular rehab expert, and a head and neck oncologist,” said Dr. Azizzadeh. Teamwork and the ability to communicate effectively are essential to getting the job done when multiple team members are required for the patient’s recovery.”

“Multidisciplinary care breeds discovery,” adds Laura T. Hetzler MD, director, Our Lady of the Lake Regional Medical Center Facial Nerve Disorders Clinic in Baton Rouge, La. “I’m better when I have my facial physical therapist’s input, and my patients have better outcomes when therapy is introduced early. Some patients, for financial or travel reasons, cannot commit to seeing our facial neuromuscular retraining therapist, and they don’t get the same understanding of their disease and recovery process and can have less consistent outcomes.”

Equipment and long-term care at these centers are top notch. Dr. Kim said that, in addition to having a superb team of doctors and nurses, the team at UCLA uses advanced microscopes and instruments during surgeries to help see what each nerve is moving within the face. She also works with a dedicated physical therapist to create customized plans of care. “All of these factors allow us to work in helping our patients achieve their potential regarding facial reanimation. “Facial reanimation surgery is a bit of a creative process, and collective input is always welcome.”

New Techniques and Treatments

According to Jon-Paul Pepper, MD, director of the Stanford Facial Nerve Center and Stanford University in Palo Alto, Calif., many of what are being called new techniques are actually existing procedures that have been refined and improved. “For instance, there are newer and better ways of treating patients with facial synkinesis,” he said. “In the past decade or so, improvements in selective neurectomy—in which individual nerve branches are electrically stimulated and selected for treatment—and refinements in gracilis free tissue transfer involving more refined transferred muscle, have been very exciting. This has led to better results for patients.”

Dr. Boahene said the way muscle and nerve transfer procedures are done now is more sophisticated than in the past and can create more facial movement. “There are many muscles that move in different vectors. In the past, we used one muscle to simulate what smile muscles do. Now we can closely mimic what can move with multivector functioning muscle transfer.”

While the gracilis muscle is strong and robust, there are no muscles in the body that are as thin as the facial muscles. Dr. Boahene and his team also transplant the latissimus dorsi from the back and strap muscles from the neck. “We choose the muscle based on its size and our ability to hide the scar,” he said.

For facial paralysis patients who need assistance with keeping an eyelid closed, Dr. Boahene uses palpebral springs inserted into the lid or gold implants. He also uses collagen implants in the lower eyelid to help push it up so the eyelids meet.

In the lab, Dr. Pepper is doing preclinical nerve regeneration research examining the signaling molecules activated by nerve injury. His team is trying to manipulate these signaling molecules to design new drug treatments. “We’re in the middle of developing a drug that can be applied to the site of surgical nerve repair to enhance the growth and migration of key cells that are needed for nerve regeneration,” he said. Currently, they’re testing a compound in mice, based on a prior research discovery, that stimulates the desired molecular signals to increase the rate of nerve regeneration after injury.

For severe facial paralysis, the challenging part, according to Dr. Pepper, is that it’s difficult to get home run results consistently. “You can make people better, but complete functional restoration for severely affected patients doesn’t really exist,” he says, adding that while results may look impressive in an isolated video or photo, the patient’s true experience is not complete rehabilitation, and both the patient and the physician must be prepared for the fact that there is still a disability. “That’s the reality of our field as it stands right now; we’ve made a lot of progress, but there’s more work to do.”

Another downside can be that patients don’t necessarily want to have to return for so many visits and procedures in the years to come. Dr. Kim said, however, that part of what makes this work so appealing to the surgeons doing it is the long-term relationships they form with these patients.

“Facial paralysis can be devastating for patients, and I’ve experienced this from both the provider’s and patient’s perspective having been a facial paralysis patient myself,” said Dr. Miller. “Facial expressions have been called the ‘universal language,’ and facial paralysis takes these expressions away. Working with and treating patients with facial paralysis is extremely satisfying—honestly, I cannot imagine a more satisfying career.”

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Renée Bacher is a freelance medical writer based in Louisiana.