Bell’s palsy is a common facial paralysis condition – more common than many people think – and whilst the medical profession doesn’t completely understand why it occurs, there are a number of commonalities and treatments available. Our cosmetic and reconstructive plastic surgeon, and Bell’s palsy specialist, Dr Dan Butler shares words on diagnosis and key interventions . . .
There are a number of theories circulating around facial weakness, with the most widely accepted being that the facial nerve – the nerve that powers the facial expression muscles – swells and becomes squashed in the bony canal from the brain out towards the skin of the face.
“This stops the nerve from working normally leading to the facial droop and weakness,” says Dr Dan Butler. “There are a number of things that can increase the risk of Bell’s palsy, including having a previous history of Bell’s palsy, pregnancy and some respiratory infections.”
And whilst it’s common practise for people to use the term ‘Bell’s palsy’ to describe any form of facial weakness, around one third facial weakness cases are caused by another diagnosis that is likely to have a very different initial treatment plan, so it’s important to get checked out early on, explains Dan.
Most cases of facial weakness will present with similar changes in facial appearance, for example, a drooping eyebrow, inability to close the eye, drooping of the corner of the mouth and an inability to smile on the affected side. Depending on where the facial nerve is affected, some patients will also have problems with dry eye and altered taste.
It’s a myth that people can’t recover from Bell’s palsy without intervention. With true Bell’s palsy (i.e. facial weakness with no other cause found) 70% of people will fully recover, says Dan.
“It is, however, important to seek early medical attention, as starting high dose steroid tablets within the first 72 hours has been shown to significantly increase the chance of a full recovery," he says. “The chance of recovery if the facial weakness is caused by something other than Bell’s palsy really depends on the underlying diagnosis – with there being more than 50 different causes for facial palsy.”
Amongst the 30% of patients that don’t fully recover from Bell’s palsy, a large proportion will develop features termed synkinesis. Which means that their muscles are able to move, but they move in an uncoordinated fashion resulting in facial pain, asymmetry and tightness.
Plastic surgery and non-invasive cosmetic treatments have helped turn the table on this common neurological condition, with a large number of options available to treat patients whose facial weakness hasn’t resolved, and those who have developed facial tightness as part of their recovery.
Treatment options range from Botox injections, through to nerve-based operations and bringing in muscles from other parts of the body. Treatments give patients the chance to improve critical functions like eye closure and eating, as well the opportunity to restore more symmetry and facial balance.
The treatment of choice depends on the underlying cause, i.e. facial weakness or facial tightness after partial recovery, the duration of the facial weakness or tightness, and the patient’s general health and overall goals.
“For facial weakness I will look to address all the affected areas of the face,” explains Dan. “This usually focuses on eyebrow, the eyelids and the smile.
“Botox and facial physiotherapy are excellent initial treatment options for synkinesis,” explains Dan. “These help to relax the overly tight muscles and eliminate any unwanted facial movements. After a course of non-surgical treatments, there is then the option of permanently weakening the muscles that aren’t offering useful facial movements through an operation called a selective neurectomy. This divides the small little nerve branches to the muscles we are aiming to weaken and acts like a permanent version of Botox treatment.”
The options for restoring smile symmetry are the most extensive and can include bringing in healthy movement nerves from other parts of the face to power the facial muscles, and bringing in strong tissues, muscles and nerves from other body areas to support the corner of the mouth and improve symmetry at rest.
As each treatment has its own indications, risks and benefits, careful consideration on a case-by-case basis is essential, says Dan.
“There are anywhere between 10 to 17 muscles involved initiating a smile. Each muscle contracts in a carefully co-ordinated fashion to ensure a well-balanced, recognisable ‘smile’,” he explains. “Although we have a number of surgical and non-surgical options available, in many cases we can’t fully replicate this complex interplay of movements. As a result, all patients will have some residual facial asymmetry, but the objective is to significantly improve things from the initial starting point.”
