Facial Palsy Treatment and Chronic Facial Asymmetry

Facial palsy occurs when the facial nerve, which controls the muscles of facial expression, is affected and the muscles on one side of the face become partially or completely weak.

Some cases improve significantly during the first weeks and months. In others, recovery may remain incomplete or the pattern of muscle movement may change as the nerve heals. This can result in persistent problems such as asymmetry of the mouth, eyebrow drooping, imbalance around the eyes, an uneven smile, involuntary contractions or synkinesis.

At Anka Plastic Surgery, many of the patients we assess are not in the acute stage of facial palsy. They present months or years later with persistent asymmetry or functional problems. In these patients, the aim is not always to restore the affected side to exactly how it looked before. A more natural result may sometimes be achieved by balancing the differences in movement, strength and volume between the two sides of the face.

What Is Facial Palsy?

The facial nerve controls the muscles of the forehead, eyelids, cheeks and mouth. When its function is impaired, patients may experience difficulty raising the eyebrow, incomplete eye closure, drooping of the corner of the mouth, an uneven smile or reduced lip movement.

Some patients may also notice changes in taste or discomfort around the ear. The severity of facial palsy and the areas affected can vary considerably from one patient to another.

What Causes Facial Palsy?

Facial palsy can develop for many different reasons. One of the most widely recognised causes is Bell’s palsy, which is usually a sudden-onset peripheral facial nerve palsy.

Other causes may include trauma, parotid surgery, ear or skull-base surgery, tumours, infections, congenital conditions, direct nerve injury or certain neurological disorders.

A newly developed facial palsy should not be approached simply as an aesthetic problem. In the acute stage, identifying the underlying cause and obtaining appropriate medical assessment are the first priorities.

What Should You Do If Facial Palsy Starts Suddenly?

Sudden facial weakness should first be medically assessed to determine the cause. If facial asymmetry is accompanied by weakness in an arm or leg, speech disturbance, altered consciousness, severe dizziness or double vision, urgent neurological assessment is required.

Patients with suspected Bell’s palsy should also be assessed by the appropriate medical team early in the course of the condition. The role of plastic and reconstructive surgery becomes more prominent when persistent asymmetry, incomplete eye closure, synkinesis or other long-term functional problems remain after the initial recovery period.

Does Facial Palsy Recover?

The degree of recovery depends on the cause of the palsy, the severity of the nerve injury and the time that has passed.

Some patients regain most facial movement, while others may continue to have asymmetry around the mouth, abnormal contractions around the eye, differences in eyebrow position or imbalance when smiling.

For this reason, regaining movement does not always mean that the face has returned to its previous movement pattern. Abnormal muscle activity that develops during nerve recovery may itself require treatment.

Chronic Facial Palsy and Synkinesis

When significant asymmetry or functional impairment persists months or years after the initial facial palsy, the condition may be considered a chronic facial palsy sequela.

At this stage, the problem is not always simply weakness on the affected side. The unaffected side may continue to move normally or more strongly, making the difference between the two sides more noticeable.

In some patients, nerve recovery causes different muscle groups to contract together unintentionally. This is known as synkinesis.

For example, the eye may narrow involuntarily when the patient smiles, or the corner of the mouth may move when the eye closes. In some patients, the affected side may also become tight or overactive rather than remaining completely weak.

For this reason, assessment of chronic facial palsy should consider not only which muscles are weak, but also which muscles are working too strongly or at the wrong time.

How Is Chronic Facial Palsy Treatment Planned?

There is no single standard treatment for chronic facial palsy. The face should be assessed both at rest and during movement.

Eyebrow elevation, eye closure, speech, lip pursing and smiling are evaluated to identify which muscles are weak and which are overactive. Differences in facial volume and soft-tissue support are also taken into account.

Some patients may benefit from a single procedure, while in others a combination of smaller treatments can create a more natural balance. The treatment plan is therefore based on the type of residual deformity and functional impairment rather than on the diagnosis of facial palsy alone.

Botulinum Toxin for Facial Asymmetry

Botulinum toxin can be used on both the unaffected and the affected side of the face in chronic facial palsy. Its purpose is not to strengthen the paralysed muscles, but to reduce excessive movement or unwanted muscle activity and improve balance between the two sides.

If muscles on the unaffected side are significantly stronger, carefully selected muscles may be treated to reduce excessive movement. Depending on the patient, this may involve muscles around the forehead, eyes, mouth, chin or neck.

In patients with synkinesis, selected muscles on the affected side may contract too strongly or at the wrong time. Targeted botulinum toxin treatment can help reduce involuntary eye closure, facial pulling or imbalance around the mouth.

Correcting Facial Asymmetry with Fillers

Chronic facial palsy can also create differences in soft-tissue volume between the two sides of the face. These differences may be particularly noticeable around the lips and nasolabial area.

In selected patients, hyaluronic acid fillers can be used to improve contour differences and reduce static asymmetry. The aim is not to restore muscle movement, but to improve balance when the face is at rest.

The amount of filler needs to be carefully controlled. Excessive volume can sometimes make movement-related asymmetry more noticeable during speech or smiling.

Treatment of Lip Asymmetry

The lips are one of the areas where facial palsy can become particularly noticeable. A patient may appear relatively balanced at rest but develop significant asymmetry when speaking or smiling.

In some patients, the lip on the unaffected side may both move more strongly and appear fuller. In selected cases, a limited unilateral lip reduction can be considered to reduce the volume difference between the two sides.

The aim is not to reduce the lips generally, but to achieve better balance between the two sides of the face.

Eyebrow Drooping in Facial Palsy

When the branches of the facial nerve supplying the forehead are affected, the eyebrow on the involved side may sit lower.

In mild cases, reducing excessive eyebrow movement on the unaffected side with botulinum toxin can improve symmetry. In more pronounced and persistent eyebrow ptosis, surgical brow lifting may be considered.

The surgical method is selected according to the degree of eyebrow descent, forehead anatomy and hairline position.

Incomplete Eye Closure in Facial Palsy

Incomplete eye closure is one of the most important functional problems associated with facial palsy. It is not simply an aesthetic concern, because persistent exposure of the cornea can lead to dryness, irritation and damage to the surface of the eye.

Protecting the eye is therefore a priority during the acute phase. In chronic cases, a small gold or platinum weight can sometimes be placed in the upper eyelid to help it close more effectively.

Lower eyelid laxity and outward turning, known as ectropion, can also occur in chronic facial palsy. Surgical procedures may be used to support and reposition the lower eyelid when required.

Facial Exercises and Neuromuscular Retraining

Simply performing intensive strengthening exercises is not always appropriate in chronic facial palsy. In patients with synkinesis in particular, uncontrolled facial exercises can reinforce unwanted muscle activity.

Neuromuscular retraining focuses on making facial movements slower and more controlled, reducing unnecessary muscle activity and improving movement patterns.

Working with a physiotherapist experienced in facial palsy rehabilitation may be helpful in selected patients.

Advanced Facial Palsy Reconstruction

Botulinum toxin, fillers and limited surgical procedures are not sufficient for every patient. In more advanced loss of movement, facial reanimation techniques such as nerve repair, nerve transfers, muscle transfers or static suspension procedures may be considered.

The appropriate method depends on the cause of the palsy, the time since the nerve injury, the condition of the facial muscles and the patient’s overall clinical situation.

Facial Nerve Repair and Nerve Grafting

If the facial nerve has been divided or severely damaged and the patient is assessed early enough, direct nerve repair or nerve grafting may be possible in selected cases.

In long-standing facial paralysis, however, the potential to reactivate the original facial muscles can decrease over time.

Masseteric Nerve Transfer

When direct nerve repair is not possible, a branch of the masseteric nerve, which normally supplies one of the chewing muscles, can be transferred to the facial nerve system in selected patients.

This technique can be used as part of dynamic facial reanimation, particularly to restore smiling movement.

Cross-Face Nerve Grafting

In a cross-face nerve graft, motor signals from branches of the facial nerve on the unaffected side are transferred across the face to the affected side through a nerve graft.

Because nerve regeneration takes time, the result is not immediate. Some reconstructions may also require more than one surgical stage.

Free Functional Muscle Transfer

In long-standing complete facial paralysis, the original facial muscles may become irreversibly atrophic. In these cases, functional muscle tissue can be transferred from another part of the body together with its blood vessels and nerve.

One of the most commonly used options is a free gracilis muscle transfer. These procedures are advanced microsurgical reconstructions and are only considered in appropriately selected patients.

Temporalis Muscle or Tendon Transfer

The temporalis muscle or tendon can be used in selected patients to create a new pulling force at the corner of the mouth.

This is one of the dynamic smile reconstruction options used in chronic facial palsy and is planned according to the patient’s existing anatomy and function.

Static Suspension Procedures

If active facial movement cannot be restored, or if more extensive surgery is not appropriate, the corner of the mouth and surrounding soft tissues can be supported in a more balanced position using static suspension techniques.

Static slings do not create true muscle movement, but they can improve asymmetry at rest and may also help selected functional problems around the mouth.

Does Every Patient with Chronic Facial Palsy Need Major Surgery?

No. The extent of treatment should be determined by the residual deformity and functional problem, not simply by the diagnosis of facial palsy.

For some patients, treatment of the opposite side with botulinum toxin, limited filler treatment, unilateral lip reduction or brow lifting may be sufficient. Others may require eyelid surgery, static suspension, nerve transfer or more advanced facial reanimation.

At Anka Plastic Surgery, the aim is therefore not to move directly towards the largest possible operation, but to choose the level of treatment that best matches the patient’s remaining function and asymmetry.

Our Approach to Facial Palsy Treatment at Anka Plastic Surgery

At Anka Plastic Surgery, we assess both sides of the face rather than looking only at the paralysed side. Facial asymmetry often results from the difference between reduced movement on one side and normal or dominant movement on the other.

For this reason, some patients achieve a more natural balance by carefully reducing excessive movement or volume on the unaffected side rather than adding more procedures to the affected side.

Depending on the individual patient, treatment may include botulinum toxin, fillers, unilateral lip reduction or brow lifting. More advanced cases may require eyelid reconstruction, static suspension, nerve transfer, temporalis transfer or free functional muscle transfer.

Our aim is not to perform the largest possible operation. It is to preserve existing function and improve facial balance with the least extensive intervention that can reasonably address the patient’s functional and aesthetic concerns.