Plastic surgery's next generation: The treatment of facial paralysis from Bell's palsy

Plastic surgery is known for cosmetic procedures, but plastic surgeons are also playing a role in the treatment of facial paralysis. Research is currently limited in this area, but some treatments have been showing promise. There is a quickly growing subset of procedures, from simple outpatient treatments to surgical intervention, in the specialty of plastic surgery.

Bell's palsy is a common neurological condition in adults that causes partial paralysis of the face or weakening of facial muscles due to nerve damage or weakness. Once thought to be untreatable, plastic surgery is working to turn the tides and show that there are, in fact, promising applications that can improve or outright reverse the symptoms of facial paralysis that are a symptom of Bell's palsy.

So, what are these treatments, and how do they work to improve facial paralysis with Bell's palsy? Are they truly effective for all patients? We spoke with one of the plastic surgeons leading the charge in treating facial paralysis – ASPS Member Surgeon Andre Panossian, MD – to answer these questions and gather more insight on how plastic surgery can treat Bell's palsy.

Applications of plastic surgery to treat Bell's palsy

It may not be as well-known as other medical conditions, but Bell's palsy is one of the most commonly experienced conditions that lead to facial paralysis.

"The vast majority [of facial paralysis cases] are Bell's palsy related," said Dr. Panossian. "In fact, I'd say it's the number one reason for facial paralysis in adulthood."

With Bell's palsy being such a big factor behind facial paralysis in adults, it's worth understanding why this facial paralysis occurs.

"Basically, there's inflammation of the facial nerve that can then shut down everything running downstream, including the muscles, which can lead to paralysis of half of the face," said Dr. Panossian. "Why it happens is still unknown with 100 percent certainty, but it's often related to a viral infection, such as the common cold or even COVID is suspected to trigger nerve inflammation."

There is no single method of approach when treating facial paralysis due to Bell's palsy, but there are some commonalities between all cases. Most often, the root cause of facial paralysis is because of nerve inflammation. Facial nerves exist as a single nerve structure that passes through the skull into the face via a tight, bony canal. When the nerve structure becomes inflamed, it can swell to a size that cuts off the rest of the nerve function.

Any treatment for Bell's palsy varies from patient to patient, but most often, antivirals and steroids are the first steps to attempt to reduce inflammation if the body is not able to counter it on its own. The results of these medications are tracked closely by the surgeon to ensure proper recovery.

"What I typically do with Bell's palsy patients, and they've already received their antivirals, I will start in an initial phase of observation for about three months," said Dr. Panossian. "This helps to establish a rate of improvement of the paralysis. Within these three months, some patients may regain some or every function of their facial nerves. We take photos and videos to establish this trend physically because it's impossible to do it objectively otherwise."

Should this process not work to reduce inflammation and compression on the nerve within three months, other interventions must be considered.

"If there has been no progress, then we have to start thinking about surgery," said Dr. Panossian. "Some practices are more comfortable waiting up to a year and a half before surgery, but I'm not – you run the risk of muscle deterioration. You really have to pay attention to how time is passing so that you can intervene at the earliest possible opportunity without sacrificing the patient's ability to recover on their own."

The surgical treatments for Bell's palsy differ from surgeon to surgeon and patient to patient. However, some treatments involve transferring other nerves to the face to facilitate facial reanimation. This is a very intensive process that will also involve extensive physical therapy following it to retrain patients in how to properly use the muscles within their face.

Even with its commonality among patients, little research has been done on the treatment of Bell's palsy, as studies must be retrospective and treatment is not standardized between surgeons.

"It's difficult to do a study on Bell's palsy, as when it happens, it's typically considered an emergency," said Dr. Panossian. "All of the research studies are retrospective, where someone has come into the ER and already received a course of steroids and antivirals. Treatment isn't standardized across the board, and some people can recover without any intervention."

Further surgical applications for the treatment of Bell's palsy

One side effect of Bell's palsy treatment that must be considered is unusual facial reanimation. Many patients will show remarkable recovery and improvement with surgical intervention, but some patients may experience some asymmetry and unusual animation of facial muscles. This is often due to the confusion of recovering facial nerves.

"With facial nerves, there are so many interconnections with the facial nerve as you go further downstream from the trunk," said Dr. Panossian. "There's feedback interaction with different interconnections – if there's an unusual branch leading off from a main branch, this can result in a spastic state of facial muscles."

A few methods can be pursued by surgeons and patients to counter this potential result.

"There are conservative means and surgical means," said Dr. Panossian. "Conservative means focus on weakening of the muscles through strategic Botox placement. It's not aesthetic, but rather placed strategically to soften the muscles without defunctionalizing them. That's the typical initial treatment that patients will require. I always start my patients on Botox first. If they're not happy with the results, they won't be happy with the results of a surgical procedure, and Botox is reversible."

Moving even further into surgical correction is when we truly see the innovative foundation of the plastic surgery specialty.

"This is sort of the cutting edge as far as surgery goes – known as selective neurolysis," said Dr. Panossian. "It involves exploring the branches of the nerves and mapping out the unusual branches. Then you sort of just splice them out to hopefully control the unwanted spasms or twitching. I've evolved this on my own to include a very targeted area of muscle deconstruction. For example, in the forehead we can knock out muscle function surgically in order to provide symmetry. I'll often do a brow lift with this type of procedure, and there's very little downside to going after these muscle groups."

As explained, surgical applications and potential treatments for facial paralysis from Bell's palsy offer amazing promise to patients. So, while plastic surgery may be most renowned for its cosmetic enhancements, it's also changing lives by restoring function for those suffering from conditions such as Bell's palsy.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.