Surgical intervention to treat facial paralysis

We may be acquainted with the idea of facial paralysis, but many of us are not as familiar with the methods of treatment for these life-changing conditions. Facial paralysis can be caused by a variety of medical conditions ranging from stroke to Bell's palsy, with paralysis being experienced partially or throughout the face.

Once considered untreatable, advancements in medical care have quickly proven that there are applicable treatments that can help to counter the symptoms of facial paralysis if not outright correct it. Plastic surgeons aren't often associated with the treatment of facial paralysis, but those trained in this subspecialty of plastic surgery are uniquely capable of helping patients regain the function of their face, whether partially or completely.

One of the leading plastic surgeons in the treatment of facial paralysis is Andre Panossian, MD. We spoke with him to get his insights on how plastic surgery goes beyond just cosmetic surgery and can help restore form and function for these patients.

The emerging field of facial paralysis treatment in plastic surgery

You might be more inclined to think that a neurosurgeon would handle something that involves nerve damage or dysfunction with it comes to facial paralysis. However, plastic surgeons can be uniquely equipped to treat a variety of conditions that cause facial paralysis. 

"It's very true that many people don't associate plastic surgery with facial nerve reconstruction or facial reanimation," said Dr. Panossian. "It seems on the surface to not make a lot of sense – we tend to think neurosurgeons due to nerves. It's obviously a very unique subset of plastic surgery – it's not front and center. There aren't as many surgical cases across the board as other fields of plastic surgery. It's more of what I'd call an academic pursuit for the most part because we're always trying to innovate and push the art. It's an area that attracts me because it's so unfulfilled because of its undeveloped treatments. Though the things that we do are new as compared to five years ago."

The phases of facial paralysis

One important consideration for the surgical treatment of facial paralysis is the phase in which the patient is in – acute (early) or chronic (late). This will directly affect the type of treatment that is available and what they can expect with a surgical intervention.

"The first year to year and a half, we consider the acute phase, where there is potential for recovery of the nerve," said Dr. Panossian. "However, once it's past that point, you're sort of stuck with whatever the appearance is or facial paralysis is, which might mean that you're stuck with asymmetry or facial paralysis."

The patient profile for facial paralysis treatment

While there are a variety of medical conditions that can cause facial paralysis, there are particular conditions that are more often seen in day-to-day practice.

"The vast majority are Bell's palsy related – the number one reason for facial paralysis in adulthood," said Dr. Panossian. "Basically, the inflammation of the facial nerve that can then shut down everything downstream, including the muscles, creating paralysis of half of the face. Why it happens is still unknown with 100 percent certainty, but it's often related to a viral infection like the common cold or even COVID is suspected to trigger nerve inflammation. What happens, theoretically, is that when the facial nerve comes out from the skull and enters the face, it's a single nerve and it passes through a tight bony canal. A bony canal like that doesn't yield to inflammation or swelling of the nerve. If the nerve is swelling due to a virus or the hormones of pregnancy, you get a total shutdown of the entire nerve downstream, leading to facial paralysis."

Patients can experience a reduction in inflammation of the nerves and relief of pressure with steroids and antiviral treatments with treatment in the acute phase, leading to the potential for regain of facial movement. However, once patients enter the chronic phase of facial paralysis with Bell's palsy, treatment may not be as effective, and a surgical intervention may be needed.

"Bell's palsy is the number one reason for facial paralysis because some of your facial movement will not recover," said Dr. Panossian. "Maybe about a third of patients don't recover, and they end up with some sort of facial weakness or paralysis that then becomes permanent."

Surgical intervention for facial paralysis

There is often a period of observation after facial paralysis patients enter treatment before they undergo surgical intervention.

"What I typically do is that if someone comes in early on with Bell's palsy and they've already received their antivirals, I start in the initial phase to observe for about three months," said Dr. Panossian. "This helps to establish a rate of improvement of the paralysis. If this happens within three months, some people may regain every function or some function of their facial nerves. At that point, we want to establish a trend and then we sort of do it in three-month intervals. We take photos and videos to establish that trend physically because you can't really objectively do it otherwise."

Following this initial observation period, surgeons will then begin to assess whether surgical intervention is needed.

"What ends up happening is that I will observe in a three-month interval with documentation on if things are improving," said Dr. Panossian. "If they are, I'm going to keep checking in every three months until I see a plateauing. If there has been no progress within three to nine months, then we have to start thinking about surgery. Some practices are more comfortable waiting up to a year and a half before surgery, but I'm not comfortable with that – 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 exact surgical intervention that is used to treat facial paralysis at this point will vary from surgeon to surgeon and case to case, depending on the results that are needed. Surgeons may utilize a variety of methods to balance the muscles and nerves, from a "rewiring" of nerves to patching with nerves from elsewhere in the body to Botox. Many surgeons will err on the side of conservatism at this point in order to preserve further function of the face and allow patients the opportunity to recover movement on their own.

"Everyone's pattern is going to be different, everyone's threshold for wanting a surgical intervention is going to be different," said Dr. Panossian. "In general, for some of us who do this regularly, it's very low risk to do this type of procedure. As time has passed and we've done more and more surgeries in this regard, we are able to avoid the problem of potentially knocking out more function."

So, while your first thoughts about treating facial paralysis and conditions like Bell's palsy may not gravitate toward plastic surgery, you can see that some plastic surgeons are, in fact, uniquely equipped to handle these cases and can help patients regain some, if not all, of their facial functionality. This innovative area of plastic surgery has recently been making waves because of the amazing results that can be achieved with minimal downtime. Through surgical interventions and careful observation, patients with facial paralysis can now hopefully expect a brighter outcome in recovery from facial paralysis.

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.