At some moment in our life, while walking on the road, we must have come across a person trying to walk with the help of either a stick in the non-paralyzed hand, or with an accompanying companion, but his/her gait is always different and unbalanced. They always seem to be putting more effort even for just standing straight. We simply ignore or pass a comment, but to the family and the accompanying companion, the burden is not about taking care of him/her, but rather, being unable to normalize their condition. We just notice what we see majorly, but when we stop to watch him/her closely, or when we directly have to take care of him/her, we also notice the minor details. Among them, and the one that is more troublesome to the person affected, is facial paralysis.
Facial paralysis is an inability to move the muscles of the face on one or both sides. It is either partial or complete, and can affect one portion, or entire half, and rarely, both sides. The age is never a factor, and the reasons causing the facial paralysis may be multiple. This condition is indeed a very challenging one for the affected person, as it not only impacts facial movement, appearance, emotional expression, and social interaction, but also critical functions like eating, speaking, properly breathing through the nose, and blinking of the eye.
The causes can be broadly categorized as congenital or acquired. Acquired condition can either be acute or chronic, depending on the length of time.
Congenital paralysis is the one that is present at birth, and as stated above, can affect one or both sides. Occasionally, it can be caused by trauma at the time of delivery, which might improve with time, but mostly are associated with developmental anomalies of the facial nerve, muscle, or syndromes.
Acute acquired facial paralysis occurs over a short period of time, which is usually less than a week, the most common cause being Bell’s palsy. Other causes include trauma, stroke, infection, autoimmune diseases, surgery, tumors, and neurologic disorders. It tends to get severe shortly after it begins, and may show some improvement with time.
Chronic acquired facial paralysis occurs over a longer period of time. Tumors growing inside the skull, or growths within the parotid (saliva) gland situated just in front and below the ear, or skin cancers spreading along the facial nerve are the causative factors. The most common benign tumor growing inside the skull is vestibular schwannoma. After removal of the tumor, some may regain function, while some may have persistent or permanent paralysis.
The treatment course can only be determined after properly identifying the cause, and depending on the circumstance of paralysis and individual, the treatment must be individualized. In some cases, waiting over a period of time allows the facial function to improve on its own, while in other cases, either non-surgical, or even surgical, intervention may be required.
Non-surgical treatment includes medical therapy, physical therapy, speech therapy, and minimally-invasive facial injections. Medications like antibiotics, antivirals, and steroids can improve certain types of facial paralysis, and that too if started early on. Physical therapy includes a specialized form of neuromuscular retraining that requires regular practice and participation by the individual. It may involve a combination of facial massage and relaxation techniques along with targeted facial exercises. For speech therapy, after assessment of the specific difficulties for moving the lips and cheeks, compensation strategies can be applied to improve this important function. Botulinum toxin (Botox) and injectable filler are the two main prevalent types of injectable treatment for optimizing facial function. Botox helps by temporarily weakening the excess muscle tightness of dis-coordinated muscle movement, while fillers help to restore the volume to various parts of the face.
Medical treatment and therapy may not improve or provide benefit to some patients or causes of facial paralysis, in which case, surgical treatment is needed. Surgical treatment can be broadly categorized as static and dynamic reconstruction. Static reconstruction means interventions that do not recreate the movement but just reposition the feature of the face for better symmetry and function. It may be done by creating a sling out of the fascia harvested to pull the angle of the mouth or any part of the face, or using a platinum or gold weight over the upper eyelid for helping closure of the eyelid.
Dynamic reconstruction restores movement of the facial muscles. This can be achieved either by facial nerve repair, or restoration of the continuity of the lost segment of the nerve, with nerve graft in the cases of traumatic or iatrogenic (during the surgery) facial nerve injury. If the nerve is not functional, then repair won’t do much, so in these instances, nerve transfer can be done. Good results can be expected if the transfer is done within two years of the paralysis; after that, even the nerve terminals to the muscles will have died.
In this case, functional muscle transfer can be done.
Being a plastic surgeon, I look forward to restoring facial reanimation with dynamic reconstruction, but static reconstruction and non-surgical treatments will definitely help those affected in the long run if he/she takes the right decision to undergo for their betterment.