Eye Effects of Facial Paralysis

The facial nerve is a branching nerve that travels from the brainstem to the face and controls movement involved in smiling, frowning, closing the eyes, and raising the eyebrows. Trauma, surgery, stroke, Bell’s palsy or infection may cause temporary or permanent paralysis (“palsy”) of the facial nerve. When this occurs, patients may have trouble closing their eyes, raising their eyebrows or managing tears on that side of the face. Symptoms may include an eye that waters, an eye that is dry and scratchy, a droopy brow or upper eyelid, or a saggy lower eyelid. Some patients will experience paralysis of the lower half of the face leading to drooling, change in speech quality, sagging of the corner of the mouth.

Although function of the affected nerve may improve in some patients over time, that function does not always return to normal. The previously paralyzed muscles of the face or eyelids may begin to relax and contract in unusual ways or in synchrony with other, distant, muscle groups (“synkinesis”). Symptoms of synkinesis include eyelid spasms, squinting when chewing foods, and drooping of the upper lid from over-action of the eyelid closing muscles. These changes are usually permanent.

Treatments
When the facial nerve is injured from trauma, stroke, infection or after Bell’s palsy, improvement can sometimes be seen over several months. During this time, some patients will find lubrication of the eye with over-the-counter tears and ointment all that is necessary. Others whose eyes don’t close well may be advised to use moisture chambers or tape the eye shut at bedtime to avoid dryness overnight. Some patients may require lid surgery to help protect or close the eye. This might involve placing a weight under the skin to help close the upper lid, tightening a saggy lower lid against the eye, or partially sewing the lids shut at the outside corner. Some of these procedures can be reversed if the function of the facial nerve improves.

If facial nerve palsy is permanent, patients usually need to continue lubricating the eye indefinitely. Surgery to lift the brow or lower face can be considered to help improve facial symmetry. There may be a role for rewiring the paralyzed muscles through facial reanimation surgery. Though most oculofacial plastic surgeons do not do reconstructive surgery for paralysis of the lower face, your surgeon can discuss the options that may be available to you.

Treatments for problems related to synkinesis are also available. Many patients benefit from physical therapy, which can help improve facial function and symmetry, especially during active movements. Eyelid spasms and drooping lids may be reduced with oral medications or even strategic use of botulinum toxin injections (e.g., Botox®). In some cases, surgery may be an option. It is important to discuss your concerns and goals with your physician in order to develop a treatment plan that works for you.

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Risks and Complications
In the setting of paralysis, it is sometimes necessary to repeat surgery as the effects wear off over time. Bleeding and infection are potential risks of any surgery. Be sure to tell your surgeon if you are on blood thinners as their use may put you at increased risk for bleeding complications.

Your surgeon cannot control all the variables that may impact your final result. The goal is always to improve a patient’s condition but no guarantees or promises can be made for a successful outcome in any surgical procedure. There is always a chance you will not be satisfied with your results and/or that you will need additional treatment. As with any medical decision, there may be other inherent risks or alternatives that should be discussed with your surgeon.