Facial Paralysis
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Facial paralysis — sometimes called facial palsy or facial nerve paralysis — happens when the facial nerve stops working properly. This nerve controls the muscles that allow you to smile, blink, and move your face. When it becomes damaged or inflamed, it can cause face drooping, weakness, or difficulty moving one side of the face.
Facial paralysis can affect both your appearance and how your face functions. You may have trouble blinking, speaking clearly, chewing food, or keeping food and liquids in your mouth. Some people also experience tight facial muscles, spasms, or abnormal movement called synkinesis. This usually happens when your face doesn’t heal completely after facial paralysis.
At UVA Health, our specialists diagnose and treat all types of facial paralysis in adults and children. We develop a treatment plan designed to improve how your face looks, feels, and functions.
Symptoms of Facial Paralysis
Facial paralysis usually affects one side of the face, but in rare cases, both sides can be affected. Symptoms can appear suddenly or develop gradually depending on the cause.
Common symptoms include:
- Face drooping
- Drooping mouth or uneven smile
- Facial weakness or inability to move part of the face
- Trouble closing one eye or blinking normally
- Difficulty speaking or chewing
- Drooling or trouble keeping food in your mouth
- Facial twitching or spasms
- Tight facial muscles or abnormal movements (synkinesis)
These symptoms may affect your ability to communicate, eat, and protect your eye from dryness or irritation. They can also make a big impact on your social life and affect your mood and self-esteem.
When Face Drooping Is an Emergency
Sudden face drooping can sometimes be a sign of stroke. Stroke is a medical emergency and requires immediate treatment.
Call 911 right away if you notice:
- Sudden face drooping
- Weakness or numbness in the arm or leg
- Trouble speaking or understanding speech
- Sudden vision changes
- Severe headache or dizziness
Even if symptoms improve quickly, you should still seek emergency care. Prompt treatment can help prevent serious complications.
Causes of Facial Paralysis
Facial paralysis occurs when the facial nerve — also called the seventh cranial nerve — becomes injured, inflamed, or compressed.
Common causes include:
- Bell’s palsy
- Ramsay Hunt syndrome
- Stroke
- Infections, including Lyme disease
- Tumors affecting the facial nerve
- Injury or trauma
- Complications from surgery
- Neurologic conditions
Bell’s palsy is the most common cause of sudden facial paralysis. It often develops over one to two days and can cause face drooping, weakness, and difficulty closing the eye. Many people recover completely, but some continue to experience facial weakness or abnormal muscle movement such as synkinesis.
It’s important to rule out other serious causes of facial paralysis (stroke, tumors, or infection) before diagnosing Bell’s palsy. If you develop facial paralysis, please seek immediate care.
Some people are born with facial paralysis, while others develop it later in life.
How We Diagnose Facial Paralysis
Diagnosing facial paralysis begins with a careful evaluation of your facial movement and nerve function.
Your doctor may examine how well you can:
- Smile
- Raise your eyebrows
- Close your eyes
- Move your lips and cheeks
Your care team may also recommend tests such as:
- MRI or CT scans to examine the facial nerve
- Nerve tests that measure muscle and nerve function
- Evaluation by multiple specialists
Because facial paralysis can have many possible causes, doctors work together to identify the underlying problem and recommend the most appropriate treatment.
Facial Paralysis Treatments
Treatment depends on the cause of facial paralysis, how long the nerve has been affected, and which parts of the face are involved. Some people recover on their own with medication alone. Others benefit from injections or physical therapy, while others may need surgery to restore facial movement or improve symmetry.
At UVA Health, we offer a range of treatments designed to improve facial function and help you regain confidence.
Treating Facial Paralysis
Facial plastic and reconstructive surgeon Sam Oyer, MD, describes facial paralysis treatment at UVA Health.
Facial reanimation surgery actually describes a group of procedures that are all directed towards improving facial paralysis. There's multiple reasons that people will develop facial paralysis. Some children are born with it, and they're never able to move one side of their face. Others get it because of trauma, or a tumor, or a surgery they may have undergone, and others get it because of an infection, or something like Bell's palsy which is actually one of the most common causes for facial paralysis. Facial reanimation really focuses on animating the face. It's exactly what it sounds like. And a lot of that focus is on bringing back a smile, improving the smile and also improving eye closure. The reanimation surgery is based on how much of the facial nerve is actually available. So for some people who have a temporary injury in their facial nerve, you can do a facial nerve graft, or a nerve transfer where you borrow a neighboring nerve and hook it into the facial nerve to try to get motion back to those facial muscles. Whenever we can, we try to restore motion to the person's own facial muscles. If the injury was longer ago, more than two years, then you can't get good motion by doing a nerve graft or a nerve transfer. You have to bring in new muscle to help give movement. So in those cases, we do a microsurgical approach where a leg muscle is actually transplanted into the face and it's hooked up to a nerve in the face to help create a smile when the patient smiles, either on the opposite side or maybe when they bite their teeth down with that nerve. Some of these surgeries are on the shorter end of the spectrum, where it's done as an outpatient procedure and a nerve transfer, a nerve graft can be done through a fairly limited incision. A patient is able to go home after the surgery is done. And they will see recovery of the nerve function in as short as four to six months. But it does take a while for that nerve to grow through and for the face to start working a bit again. Longer surgeries that involve muscle transfer typically require a hospital stay of about two to three days. This is to make sure that the muscle is healthy and that everything is healing well before going home. At UVA, we have doctors and providers who are specially trained in this and dedicate a lot of our time and efforts, both in research and in clinical care towards facial paralysis. So we have a whole team that can help a patient from start to finish, and we offer the full spectrum of treatment, from in-office Botox procedures, all the way up to microsurgical reconstruction.
Physical Therapy for Facial Paralysis
Specialized forms of physical therapy (often called neuromuscular retraining) can help people improve function when their face is recovering from paralysis, or reduce tightness and synkinesis. This type of therapy is very different from traditional physical therapy, and should be directed by a specially trained therapist. At UVA Health, we have a physical therapist with specialized training and years of experience treating people with all types of facial paralysis.
Botox for Facial Twitching (Synkinesis)
Facial twitching or tightness can occur when facial muscles move at the wrong time. This condition, called synkinesis, often develops after incomplete healing of the facial nerve and can happen up to 30% of the time after Bell’s palsy.
Botox injections can relax overactive muscles and help restore more balanced facial movement. Treatment is performed during a short office visit. Many people combine Botox therapy with specialized facial physical therapy to improve muscle coordination and control.
Facial Nerve Transfer Surgery
When facial paralysis develops suddenly but the facial muscles are still healthy, surgeons may be able to restore movement by connecting a nearby nerve to the facial nerve. This is called facial nerve transfer.
One common technique uses the masseter nerve, which normally controls a chewing muscle, to help restore a smile. Over time and with physical therapy, many patients learn to produce natural smile movement again that is triggered by clenching the teeth. Other nerve transfer options include the hypoglossal (cranial nerve 12) nerve that controls tongue movement or the facial nerve from the opposite side of the face. Our facial nerve surgeons will help determine which option may be right for you based on your unique situation.
Gracilis Muscle Flap Surgery
If facial paralysis has lasted longer than about two years, the original facial muscles may no longer function. In these cases, surgeons can transfer a small muscle from the inner thigh, called the gracilis muscle, to the face.
During this procedure, surgeons connect the muscle to blood vessels and nerves using microscopic surgery so it can move more naturally. This advanced technique, called a gracilis muscle flap, can help recreate a smile and restore facial movement. Read about gracilis muscle flap surgery.
Temporalis Tendon Transfer
The temporalis muscle helps you clench your jaw. Surgeons can reposition the tendon from this muscle to lift the corner of the mouth and create a small smile.
Because this procedure uses an existing muscle, patients often see movement immediately after surgery rather than waiting for nerves to regrow. Read about temporalis tendon transfer.
Selective Neurectomy & Myectomy Surgery
Some people develop tight or unwanted facial movements after the facial nerve heals incompletely. Selective neurectomy and myectomy surgery can improve facial balance by weakening specific nerve branches and muscles that cause abnormal movement.
During a selective neurectomy, surgeons carefully identify and modify small nerve branches that trigger unwanted facial motion. A myectomy may also be performed to release or remove portions of muscles contributing to tightness or pulling in the face or neck. Often, these surgeries are performed together for best results. They are also commonly done along with Botox and personalized physical therapy.
Together, these procedures can reduce facial tightness, improve smile symmetry, and help facial movements appear more natural. Read more about these surgeries.
Facial Suspension to Improve Symmetry
Complete facial paralysis can cause the cheek, mouth, and jawline on one side of the face to droop. Facial suspension procedures help lift and support these areas to improve facial symmetry at rest.
During this procedure, surgeons may use a thin strip of tissue from the thigh or other supportive materials to gently elevate the corner of the mouth, lips, or nostril. This can improve facial balance and may also help with speech, breathing through the nose, and drooling.
Facial suspension is sometimes performed along with other facial reanimation procedures to restore both movement and facial support.
Eye Protection Procedures
Facial paralysis can make it difficult to blink or fully close the eye. Protecting the eye is an important part of treatment because the surface of the eye can become dry, irritated, or damaged. In severe cases, this can even lead to vision loss. Our surgeons work closely with eye specialists (ophthalmologists) to keep your eyes as healthy as possible.
Eyelid & Brow Procedures
Facial paralysis can also make it difficult to fully close the eye or keep tears from spilling over the lower eyelid. In some cases, the eyebrow droops significantly and can get in the way of vision. Procedures such as brow lift, eyelid weight placement, or lower eyelid lift can help protect the eye and improve facial symmetry. Read more about these procedures.
Corneal Neurotization
When facial paralysis affects your ability to blink or protect your eye, the surface of the eye (the cornea) can lose feeling or become damaged. When severe, this can lead to ulceration or even vision loss. Corneal neurotization is a specialized procedure that restores nerve function to the cornea. During surgery, a healthy nerve from another part of the face is connected to the cornea so new nerve fibers can grow and restore sensation over time. This can help protect the eye, improve comfort, and reduce the risk of vision problems.
Facial Paralysis Specialists at UVA Health
Treating facial paralysis requires expertise from several specialties. Your care team may include specialists in facial plastic surgery, head and neck surgery, microvascular surgery, neurology, neurosurgery, otology, ophthalmology, physical therapy, and mental health.
This multidisciplinary approach allows us to create a personalized treatment plan based on your symptoms, goals, and the cause of your condition.
Recovery & Long-Term Outlook
Recovery from facial paralysis varies depending on the cause and the treatment used. Some people recover quickly, while others need ongoing therapy or surgical treatment to restore movement.
Procedures such as injections may provide relief within days, while nerve or muscle surgeries may take several months before movement improves. Your care team will guide you through each stage of recovery and help you achieve the best possible outcome.