Facial Paralysis Question & Answer with Dr. Azizzadeh – February Facebook Live

Good morning, everyone. This is Doctor Azizzadeh. Today we’re gonna do a Question & Answer and hopefully we’ll be able to give you some responses about some of the questions you may have about Facial Paralysis and Facial Nerve Palsy.

Q: In 2011, during my first trimester, I was diagnosed with Bell’s palsy during pregnancy. I’ve tried everything from the regular medicine to acupuncture, electrical stimulation of facial muscles, yet, I still have problems with my eye and the side of my mouth that was affected by Bell’s palsy. Do you think my only option left is surgery?

A: Typically speaking, this is very common. Bell’s palsy, and sometimes trauma, that can cause facial paralysis, but causes a reversal of nerve issues. What happens is the facial nerve and the nerve in the brain travels through the bone behind the ear, comes out and branches out to multiple different areas of the face. It goes to the small muscles, to the eye muscles, to the eyebrow, to the neck muscle where grimacing occurs. With Bell’s palsy, we get a nerve disruption at what we call the geniculate ganglion. The nerve kind of interrupts right around here, but the nerve doesn’t get completely paralyzed because these nerves start retracing and coming back alive. However, in about ten percent of patients, these nerves cross-connect, so if this nerve was supposed to go to the eye area; it goes to the eye area, to the smile area, to the frowning area. This is what we call synkinesis. When that person is trying to smile, their eyes are also closing, their grimacing muscles, which are down here, are activating, so instead of the smile going up, the corner of the mouth comes down. When the eyes aren’t supposed to shut, anytime you’re smiling the eyes have to shut, so as a result we end up with synkinesis and synkinesis is a very challenging problem because most doctors you’re gonna go to they’re gonna say, “Oh, well, your nerve isn’t really paralyzed so go on and live with your life,” but it’s a pretty devastating and debilitating, emotionally challenging process.

What do we do about synkinesis from a treatment standpoint? If this process has more than a year or two removed from the time you got your paralysis, you need treatment. The treatment options for synkinesis are the following.

First, we do not want to do electrical stimulation because we’ve seen – there isn’t perfect data, but there is some data that electrical stimulation can actually worsen the synkinesis, so that’s the first thing you want to avoid, even during the recovery period.

The second thing we want to do is because some of these muscles are very tense, we want to do rehabilitation, physical therapy, where they’re stretching, and you’re also doing some mirror exercises to help improve your smile with feedback.

Botox is also an option. Botox, basically, is a product that’s injected into certain muscles and it reduces the activity of muscles. So, people are thinking, ‘Well, I have paralysis, you’re gonna reduce the activity of muscles?’ Yes. In synkinesis, because there’s some hyperactivity, especially around the eye area and in the neck area, we tend to put a little bit of Botox to reduce the activity. Now, the key thing is that it’s got to be done in the right place and by an expert, so make sure that your doctor has experience with synkinesis Bell’s palsy Facial Paralysis, otherwise other issues can come about and sometimes we also use Botox on the opposite side.

The last thing that we do, which has been very, very effective, and this is a procedure that I’ve pioneered, is a surgical procedure where we, through a limited incision around the ear; it’s basically the same incision that we use for facelifts, we go and identify these litter nerve branches that are causing the corner of the mouth to come down. We actually do an electromyography, or EMG, in the operating room, and whatever nerves that are causing the corner of the mouth to kind of drag down, we reduce the activity of those nerves. This is called selective neurolysis. We also reduce the activity of this big muscles that’s causing the corner of the mouth to become numb. Because, if you could see, this is the zygomatic major, so this is the main smile muscle. These muscles are all grimacing and frowning muscles. And guess what? If you have synkinesis, these are gonna really be a lot more activated when you’re smiling rather than this little, little, tiny muscles. So, in the surgery, which is a very elegant operation, we reduce the activity of these nerves and this muscle through a very simple procedure and the patients do extremely well in improving their smile, the tension in their neck. And, we’ve done statistical studies, with blinded observers, who have looked at the results of the smiles, so both patients have reported improved outcomes, independent observers have seen improved smile, and the results can be really, really quick. So, the answer to Cynthia’s question is: Do you think surgery is my only option? It really depends. If you’re really, you know, having difficulty with your smile and the process, yes, surgery, plus physical therapy and Botox, together, really gives us the best technique for improving the outcome.

Q: Are there any good options for restoring a blink? I already have full eye closure and a platinum weight, which made my eyelid droop regardless of the weight that was trialed.

A: For patients who have facial paralysis, but don’t get recovery, typically speaking, their eyes are not able to close completely and this is a major issue that we want to address because when we’re looking at eye function, it’s not just the blink that’s important, it’s the protection of the eye. If your eyes are not able to close completely, the eye can get dry, can get excoriated, can lead to blindness, so it’s really important that, if you don’t have complete eye closure, that all day you use artificial tears; at night you use lubrication, or even during the day you use lubrication; you tape your eyes shut at night, so those are immediately very, very, very important aspects of the health of your eye. Now, once we’ve determined, okay, this is a short-term process or a long-term process, if we feel that the eyes are not gonna close long-term, then we want to address eye closure. And, typically speaking, the most, I would say, currently, the ideal treatment option is using a platinum weight, but it needs to be done in the right place, in the right position, and aesthetically, so that you don’t see the contour. A platinum weight, basically, is put in through a very, very tiny incision on the eyelid, the same incision that we use for blepharoplasty or eyelid lifts, and we place it in a position that’s contoured, brings the eyes down, and aesthetic. Now, this does not restore blink reflex. A blink is our natural, spontaneous, eye closure. It does not restore that, and, as a result, a lot of people are still seeking natural eyelid restoration of the blink. This operation improves eyelid closure but it does not improve blinking. The only main option of blink restoration is with a procedure called a spring, which is a titanium, metallic spring that’s put into the eye and it helps the eye close in a more natural way. however, the problem is that, a lot of patients need multiple revision surgeries to get that right. And, as a result, because the eyelid closure is generally well-tolerated with platinum weight, most of the expert facial nerve experts utilize platinum weight, but I do think that it can be done really nice and aesthetically, if it’s done well, and that’s pretty much how we offer eyelid closure for patients that can’t completely close their eyes.

Q: Does smile surgery fade away with time or does it permanently keep the muscles stretched for longevity?

A: There are many different smile surgeries and we just described one type of smile surgery, which is called selective neurolysis. There are other smile surgeries that we utilize, for instance, the muscle from the inner thigh. This is called a gracilis free flap. There are other muscles surgeries, such as a temporalis tendon transfer. These are all used depending on what the underlying cause of facial paralysis is, what the patient’s desires are, and so forth. Generally speaking, most of these operations are permanent operations. However, when someone has facial paralysis, the two sides of the face will age differently, will go through a different process. I always tell all my patients that we need to be on top of the entire – your lifelong process – because we’re gonna need to, maybe in about five to ten years, tweak certain things, or change certain things, or add certain things because your two sides of your face are gonna age differently. As a result, we do tend to – I tend to really want to see my patients long-term and I have, you know, patients that have been with me as long as I’ve been in practice. Does it fade? No, but some patients may need touch-up surgery, some patients may need revision surgery, some patients may need other treatments.

Q: I had facial paralysis about two years ago and it did not heal completely. Is there any way to heal?

A: Most doctors say, ‘Okay, one year is the time period after facial paralysis that we kind of want to do something,’ but it really depends on what we’re considering healing. If your face appears to have some regaining of tone, some movement after facial paralysis, after you’ve had facial paralysis, then we’re gonna give it some time; a year, year and a half, two years. If someone’s had facial paralysis and we don’t know what the cause is and there’s no regaining of tone, we want to do investigation immediately. Typically, I wait about three to six months, but really at the three-month mark, if there’s no regaining of tone – let’s say a patient had Bell’s palsy and we consider anyone to have Bell’s palsy if we can’t find a source of their facial paralysis – but after three months, their face still does not have any tone or any movement, we want to be very, very – we want to get an MRI, we want to do – they get another full evaluation of your facial paralysis, so we want to make sure that we are finding a cause for it. There are two different circumstances. Number one is if there’s no cause found and there’s no regaining of any tone or movement, that’s, basically, what I would call ‘you need to see a doctor immediately.’ If a patient has had some regaining of tone, movement, but their face has synkinesis like what we described earlier, or kind of difference in movement, then I think you can wait a year, year and a half; you can kind of give it a little bit of time. Typically, what you see after a year, year and a few months, is what you’re gonna have and that’s when start treatments.

Q: I had facial nerve schwannoma and got surgery in 2012. I had a facial nerve grafting too. It looks okay in residual position, but falls down while smiling. Can it be recovered completely?

A: Typically, acoustic neuromas are in this area, so the nerve was somehow interrupted right in this area and a nerve graft was placed in. Now, what we had described earlier with synkinesis is probably what you’re experiencing, you don’t have direct control of movement and every time you’re trying to smile we’re seeing this downward movement of the corner of the mouth. The same operation that I described earlier for patients with Bell’s palsy, where we go in and reduce the activity of these nerve branches that are causing your corner of your mouth to go down, is an excellent option for you. Now, depending on your age and other factors, we also do some static procedures at the same time, such as asymmetric facelift, eyelid surgery, brow lifts to kind of create symmetry. Now, some patients may require more advanced procedures, like nerve grafting from the ankle to connect to the opposite side of the face and gracilis muscle grafts where we actually bring in fresh muscle to help aid the corner of the mount movement so there are options. But, yes, I think you definitely are a candidate for surgery. The question is, what type of surgery? I have to kind of see what your smile is like and what the situation is and some other factors. But, the likelihood that you’re gonna get better without doing anything is very low. But, with treatment, surgical options, and maybe even some other options, there’s definitely hope.

Q: My son has had a cross-face nerve graft, do you think it is important to do facial exercises after that or it wouldn’t matter either way?

A: I’m assuming that your son was either born with a facial nerve paralysis, had a congenital case of facial nerve paralysis, or had some other cause that required a cross-face nerve graft. To explain a cross-face nerve graft, essentially, if you have, let’s say, paralysis on your right side, and most of the time, either complete or really severe case of paralysis, what we can do is utilize the normal nerve on the left side; attach a nerve graft, which was call it a cross-face nerve graft, and utilize that nerve graft to either attach it to a muscle, which typically is a gracilis muscle or a muscle from the inner thigh that helps the paralyzed side move, and this is a great operation for young patients or even adults who have complete paralysis and who have not had treatment.

I do think facial exercise are really important in those cases because the brain needs to retrain, and when it’s not the exact side of the face that is moving, we really want to get that physical therapy, neuromuscular retraining on facial exercise, and I do think that, especially after you start getting movement, it’s a very, very important approach.

Q: I’ve had Bell’s palsy for going on three years. I’m 19-years-old. I’ve been offered cross-face nerve graft, as well as a labbé. Could you give me information on the labbé please?

A: There are two different approaches to a labbé operation. Someone who’s had Bell’s palsy, typically speaking, has a significant amount of synkinesis if they have not had an improvement, so the three options that we generally want to consider is the first option that I talked about which was the selective neurolysis where we go in and reduce the activity of those downward tractions, so that’s one option. The second option is the labbé, which, basically, the muscle – and let me kind of – so the temporalis muscle is the muscle of chewing that’s in this area and it typically has a tendon that we can attach to the corner of the mouth and by biting down the corner of the mouth may move. Now, the benefit of this operation is that it’s effective in moving the corner of the mouth; it’s a one-stage operation, and there are several other terminologies for it: orthodromic temporalis tendon transfer, or temporalis transfer, different variations of it. The disadvantage is that you have to bite down to move the corner of the mouth, so it’s not a spontaneous movement. So, I like the labbé but I generally reserve it for patients who are much older, who have had a lot of surgery in the parotid area or head and neck area, and/or for very young patients with Moebius Syndrome as an option. So, typically speaking, for your age group, again, depending on what the situation is, I like the selective neurolysis or the cross-face nerve graft because I do think those options are spontaneous and give you spontaneous movement so you don’t have to think about biting down and moving around. So, that would be the difference. Again, our ideal option is always to give you spontaneity, an emotional smile, emotional movement while you’re speaking. Because, even if you can move the corner of your mouth, 90+ percent of our time is talking with each other and during that conversation, we want both sides of the face to move spontaneously and the cross-face nerve graft and the selective neurolysis are really the two best options for spontaneity. Lbbé, excellent operation, excellent surgery. I reserve it for a different patient population.

Q: I’ve had a second attack of Bell’s palsy and the second one developed synkinesis. I can’t raise my eyebrows and my lips are crooked when talking and pouting. I’m on my eighth month now. Can you do surgery at this time?

A: We want to really wait. Even though it’s your second attack, typically wait. Again, nine to twelve months after a bout of facial paralysis, whether it’s Bell’s palsy or some other, unless we know the nerve has been completely cut, we need to go in fast, correct it. If the nerve, for instance, we think there’s a tumor or some sort of cancer that’s causing the nerve to be affected, we want to go in immediately. But if it’s a known case of Bell’s palsy or a known cause of ideology, typically a year after.

Q: I came down with Bell’s palsy in the early ‘80s with no treatment at all. Is there anything that can be done at this point?”

A: Yes, that’s the one great thing about facial paralysis; it doesn’t matter when you had it. We have now a lot of options that are available for treatment. I think the photo that I have of Quinda, she looks like she has a significant amount of synkinesis, which is what we talked about earlier. So, for patients, whether it’s ten years ago, a year ago, or twenty years ago, options of selective neurolysis, cross-face nerve graft, gracilis flaps, labbé treatments, like we were talking about; temporalis tendons transfers, asymmetric facelifts, brow lift procedures, eye lift procedures, Botox, neuromuscular retraining. These are all options that are definitely, definitely available to us.

Q: For alternative treatments including acupuncture for people with long-term facial paralysis issues, can you provide any perspectives on what you feel is in the category of ‘go ahead and try it, it won’t hurt’ versus ‘don’t do it, it could cause harm’?

A: This is an awesome question because we get this all the time. So, pretty much, these are the things that we know. If you get Bell’s palsy, which is – patient wakes up in the morning and their face is drooping, you’re gonna go to the emergency room and you’re gonna go see a facial nerve expert immediately. That’s something that immediately you need to go see someone. They will do a physical examination, they will do a good history; they will look and make sure there’s nothing that they can physically see, and we know that steroids, at that time, as well as anti-viral medications, will help reduce the likelihood of synkinesis, which is that kind of aberrant regeneration that we talked about earlier. Those things we know. There have been studies; great outcome. Everything else past that, we don’t have definitive studies; we don’t have definitive answers to know if they’ve worked or not worked. So, a lot of it is what we call anecdotal. Now, what have people recommended and have done that I think, go ahead and try, you know, using various vitamins, herbals, and medications. You know, those things typically, herbal products, you know, vitamins, go ahead and try it. I don’t, you know, it’s hard – again, we don’t know; we can’t be sure, but I don’t think those are a major downside. Acupuncture, I actually love Eastern medicine. I think it really, with Western medicine, can really help people. would say, as long as electrical stimulation is not utilized, go ahead and try it, but electrical stimulation, again, we don’t have definitive studies, but a lot of facial nerve experts right now think that electrical stimulation does, potentially, lead to synkinesis, and this is a term that we need to really learn more about because synkinesis is what the residual issues are for the majority of patients who have facial paralysis. I hope I answered that question. But, typically speaking, I would avoid electrical stimulation if we can.

Q: My son is now 13 and was born with Moebius Syndrome. Can anything be done to help him close eyes, close at night, and help his short tongue for speaking more clearly? He gets bullied so much is now having behavior issues.

A: Moebius Syndrome is probably one of the most challenging causes of facial paralysis for us, not only to treat, but to really, I would say, the emotional aspects on the kids is really challenging. We already know kids that don’t have any craniofacial issues, that are pretty normal, walking around, they already have a challenging time with being in middle school, especially at the age of 13; it’s tough. Moebius Syndrome, the issue is that the emotional connection between the kids and their peers is very challenging because they can’t, even when we do great surgery, such as the labbé, such as gracilis muscles that we can do, it helps restore their smile and improve their smile, but it really still doesn’t give connectivity and that’s what’s very challenging. Socially it’s a major issue. As far as eyes go, because of the lack of function of the eye opening and closing, really the only option, the main option, is to utilize the platinum weight, and tightening procedures of the lower eyelid to help the eyes close. As far as the short-term for speaking, if they have tethering of the tongue, that area can definitely be treated by a head and neck surgeon, or a otolaryngologist, a pediatric ENT specialist; it really depends on what the level of the shortness of the tongue is. I know this is a challenging issue and it’s one that’s really, especially kids with facial paralysis, really has a special place for me because the treatment impacts them so amazingly, but we still have long way to go to get them to the next level.

Q: I already have a gold implant on eyelid on the right and as suggested by you, a facial nerve graft from neck. I am 30 years old now. What do you recommend can be done further so I can discuss it with my doctors?

A: The main issues is gonna be, how is your smile at this point? Can we optimize that? How is your eye closure? How is the health of your eye and how’s your emotional status of managing this? So, those are all things that are very important. And, at the end of the day, you know, we have to really look at those factors. So, can we maximize your smile? Can we make your eye closure better? Do we have symmetry between the two sides and are there treatments, both nonsurgical and surgical, that can help with that? I probably need to see your face, your smile, and your appearance to be able to give you a little bit more detail than that.

Q: I’m going into my thirteenth week into Bell’s palsy. I had no movement for nine weeks; everything started going back to normal after that ninth week. My lower lip is still not working. Should I expect to see recovery, as well? Also, my eyebrow is not there.

A: Your history is actually right on. Nine weeks you started getting some movement and at thirteen weeks, about three months from the time of your paralysis, so you’re on your pathway. Now, there may be, at the end of the year, some residual impact, but 90 to 95 percent of patients that are in your situation should recover very, very, very well. I’m hoping that you will fit into that 95 percent category and if there are any issues come back, contact us, or our next monthly Facebook Live. Please send us some questions and hopefully we’ll be able to answer.

Q: With Bell’s at one year, having nerve pulses for about eight months at night, which can sometimes awake me. Pulses are on the Bell’s side and seem to be generated above the ear and spread through the face. When fully awake, the pulses disappear or stop. Is this normal or good in regards to healing?

A: I would say that this is probably not something that we – you know, you may be having tension that you’re noticing as pulses, but I would say that i would probably get a high resolution MRI of the track of the facial nerve just to make sure there’s no other process going on. It probably will be completely normal, but again, unless I see you or I’ve examined you, I won’t be able to definitively tell you. But, kind of as a gut feeling, my first inclination is, you know, let’s do a little more investigation to see why you’re developing these pulses. This is not, typically, what we hear or see. Uh, it probably will be, you know, not a major thing, but I would definitely consider getting an MRI to just double-check and make sure there’s nothing going on in that area. If you could see a facial nerve expert, that would be great because then they can have a little bit more understanding of what’s going on with the Bell’s palsy.

Q: I got Bell’s palsy one year ago. I have recovered 90 percent, but I started to feel synkinesis and I would like to know how I can improve my condition and to get rid of those side effects. I have started with massage and stretching the facial muscles. The one effected is in the muscle and I feel very uncomfortable sometimes. I would really like to know if I will start doing Botox injections if there’s any condition to helping the synkinesis to go away.

A: This is a question I get all the time: Will my synkinesis go away? It’s a hard question to answer, but I’ll try to answer it because, again, I’m a very scientifically-oriented person. I want to know the science; I want to know the underlying process; I want to know what’s going on so that we can have a better understanding. But, typically speaking, synkinesis, I do think that it can get better; it can get worse sometimes, unfortunately. Now, how much better? It varies. How much worse? It varies. But, I would say there is kind of a status, up and down situation with most people who have synkinesis, especially if it’s there after a year, year and a half, of having Bell’s palsy or some other facial nerve disorder. So, the question becomes, do you just let it be and hope for it to get better, or to do something? And that really depends on how much it’s bothering you. If it’s bothering a severe – a significant amount, then I would seek help and we talked about physical therapy is excellent, stretching exercises, neuromuscular retraining, facial exercises. Botox I think is excellent in terms of reducing some of the hyperactivity around the eyes. And, again, surgery is excellent. It really depends, ultimately, what your long-term issues are and what your long-term goals are and how much it’s bothering you. So, basically, I would kind of really look at how much it’s bothering you. And one other thing that I want to talk about, especially on this; there is a significant amount of emotional issues that come along with Bell’s palsy, or facial paralysis, and one of the things that people just get so frustrated is they go tell their doctors, “I have facial paralysis,” and the doctor goes, “I don’t see anything,” and they kind of dismiss people. Now, obviously, when someone really has a major – like, we talked about Moebius Syndrome; if you have complete paralysis, those things that people notice right away, yeah, they empathize with. But, people who have, like, reversible, like Bell’s palsy, or synkinesis, I think they get really frustrated because there’s a huge amount of emotional issues that can come about; I mean, self-confidence, your communication skills, your socializing and people don’t want to go out. So, I really urge everybody, if you feel like depressed, if you feel anxious, if you feel insecure, if you just don’t feel like socializing, seek help from a psychologist because that’s an important part of treatment because we all need – we already – most of us need, you know, some sort of support from that end because I can only – or your doctors can only give you, you know, surgical or non-surgical, or approach, but we can’t give you that emotional support that you need, so please make sure that if you feel down and so forth, seek emotional support, as well. This is a tough problem; it’s really frustrating. Life is hard as it is, then you add on one other factor, such as, you know, facial paralysis, synkinesis; it’s pretty hard.

Q: Is it possible to correct small excursion if the gracilis is placed wrongly without the need of a second gracilis free-flop?

A: This is where gracilis free-flop is phenomenal. If you have complete paralysis of this side, from a brain aneurysm, and you have facial paralysis, even if it was 20 years ago, 15 years ago, 10 years ago, there are options. And, the most common thing that I like doing for patients, in those cases, is a two-stage operation wherein the first stage we do a cross-facial nerve graft, which is a nerve graft that goes from the normal side of the face to the paralyzed side. Then, a few months after, we go and put in a gracilis muscle, which is a muscle that we get from the inner thigh and we put that in place of – let me show you here – we’ll put the gracilis muscle – you see this muscle that’s our normal smile muscle? We’ll replace that right here. If it’s done right, and if it’s done appropriately, then we’re able to get a spontaneous smile excursion, and that really allows us to get that emotional movement and so forth. And, whether you’ve had an acoustic neuroma ten years ago, a brain aneurysm, or other brain tumor, or a severe case of Bell’s palsy, or trauma with the temporal bone fracture, or Moebius Syndrome, that you’ve never treated, that’s one option that’s really, really fabulous, and we can do, regardless of timing.

Q: Is an orthodromic temporalis tendon transfer a better option and where is this procedure being offered? Who is a candidate for this procedure and what would be the estimated cost?

A: So, orthodromic temporalis tendon transfer is what we had talked about earlier, which is that labbé procedure. And, as, you know, we discussed earlier, it is an excellent option. I love the procedure for the right patient. And, typically speaking, every patient has a different history, as you’ve noticed now, so you have to decide what the optimal option is for the patient. And, in my practice, I use it on multiple different scenarios. Most commonly, I would say, if someone has had a parotid tumor or parotid cancer, or head and neck cancer, radiation, major paralysis, a bit older population, it’s an easy, simple, two-three-hour operation; works really well in that patient population. I also offer it for young children who have Moebius Syndrome and I offer it to, sometimes, younger adults, depending on their circumstance and situation and cause of paralysis. In terms of where to find this, I would say that probably around the country there aren’t that many people that do this operation, so make sure that you ask the surgeon how many they’ve done. With all of these facial paralysis issues, you really want to have a surgeon that really deals with a lot of patients with similar circumstances. And you don’t want, as you see, there’s no one cookie-cutter procedures. You want to make sure, you know, they have multiple different surgical techniques so that they could kind of customize it for you. And, as far as cost goes, it really depends on the surgeon’s experience, expertise, you know, and other factors.

Q: Bell’s palsy is the monster that makes us like monsters. I feel beautiful after Bell’s palsy, but I want my smile to not be crooked or my eye not to get smaller. I have my days when I’m sad because of this; a sensitive subject that people use against me.

A: As we talked about the emotional aspects of this issue is major and that’s why, you know, one of the things that we really try to do is, you know, through the Facial Paralysis and Bell’s palsy Foundation, and through support groups, because not many people have friends who have Bell’s palsy or facial paralysis, unlike other diseases, like heart disease and cancer and so forth, they’re a lot more support. It is very difficult; it’s very challenging, so we definitely are, you know, sensitive to that. As far as treatments go, I think we’ve talked about of it. For narrowing of the eyes, Botox is excellent. Sometimes we combine that with surgery. As far as the smile goes, the selective neurolysis and the platysma surgery that we talked about earlier is an excellent option, and, sometimes for severe cases, you want to consider the temporalis tendon transfer and the cross-face nerve graft with the gracilis, so there are a lot of options with that.

Q: Can partial facial paralysis synkinesis be helped 24 years after surgery? What are your suggestions for working on this?

A: Absolutely. I think that’s the one great thing that I would say now more than ever. When I started kind of doing this type of surgery two decades ago, you know, there was like really a couple of options and most people were sent home. Now, regardless of how long your paralysis has been there, whether it’s partial synkinesis or total, we definitely have surgical options available for you and can discuss, depending on what of paralysis, what options you have. So, it’s a great time for treatment.

Q: I would do anything to get my smile back. It’s like a curse.

A: Just going back to the emotional side of things, this is a very, very, very challenging process and problem for most people, and we definitely want to do everything we can to get the smile better and get your symmetry better and help with the emotional aspects of it and the psychosocial aspect of it, which is very, very, very important.

Q: I have had Bell’s palsy since I was a baby and had an operation when I was younger. It affects the left side. I still cannot smile, which holds me back a great deal.

A: Great question because it brings up one of the issues with Bell’s palsy, which there are a lot of people who have had Bell’s palsy in and around their pregnancy; either during their pregnancy or right after and it’s, again, going back to the emotional side; it’s very, very challenging. You have a great, amazing thing happening with your baby, but you’re undergoing this process. But, yeah, I think there’s a lot of options and I don’t know what surgery you had when you were younger, but there are definitely treatment options, non-surgical and surgical, to help you regain your smile.

Q: I had two surgeries; one temporalis muscle transfer and one gracilis free muscle transfer, both unfortunately do not work for me. Do you have any other options for me?

A: So, this is what we call kind of salvage facial paralysis surgery. Patients have had multiple different treatments and nothing has worked. And, the way I look at it, we have to go back to a new starting point. We have to kind of go back and think outside the box. So, Arshad, I really have to see what your face looks like, what your smile looks like, to be able to give you an exact treatment. But, yes, there’s definitely options. It’s not gonna be as easy as if you hadn’t had those treatments, but I’ve had really, really a lot of success with patients like you with redoing their cross-face nerve graft, utilizing sometimes a masseteric nerve for the gracilis flap, and just going back through and kind of revising everything. So, there are options; it’s not gonna be easy, but there are definitely options.

Q: It took four years of me saying something isn’t right with my daughter. The left side of her face doesn’t change with emotion and her eye doesn’t close completely when sleeping. I’ve been told it’s her seventh cranial nerve. Would that sound correct?

A: It sounds like she has what we call either congenital or developmental facial paralysis. This is different than Moebius. Moebius is when both sides of the face do not show any expression, or movement, or smile, but the timing, from a treatment standpoint, is actually great. We, typically, for kids who are born with facial paralysis, typically want to start treatment at the age of four or five because we want to get them to really their ideal, optimal outcome before they enter middle school, or elementary school; the earlier the better, but typically we start at the age of four, and in situations like this, we, typically, utilize a cross-face nerve graft with a gracilis-free flap and sometimes also use a masseteric nerve to double innervate the muscle, and the results are excellent, really, really excellent. The success rate in younger children is really great. And, again, I have to, obviously, get a full history and see the exact situation, but there’s definitely hope. The signs are there and I would start looking for options soon.

Q: Besides Botox, is there any surgical procedure that may improve the eye synkinesis?

A: Eye synkinesis, typically, if Botox is done well and if the situation isn’t severe, I think Botox, for most patients, not all, works well. Surgical options do include – we, sometimes, go ahead and do an upper lip blepharoplasty, but we take a little bit of the excessive hyperactive muscle with that. And, for really severe cases, the same thing with the selective neurolysis that we talked about here, we can do for around the eyes, so there are options still. But, there are options still, but I would say let’s try to maximize your Botox first before jumping into surgery.

Q: I was born with facial paralysis and have had many surgeries including labbé. Can you tell me how long facial paralysis surgeries are expected to last? My labbé was five years ago. Will it last for the rest of my life or will there be a need for more surgery?

A: As we discussed earlier, I think if you’ve had an excellent result with your surgery, it should last you a lifetime. What will not last, in terms of your symmetry, is gonna be that once side of your face will age differently than the other side. So, I would say about every five to ten to fifteen years, most patients, if they want to have the best possible, optimal outcome, will need some sort of maybe touch up. But, as far as the surgery goes, itself, the labbé, if it’s working now, it should work for a long time to come.

Q: Any thoughts on research or other new treatments that would give patients hope for future breakthroughs?

A: There is actually. There are a lot of great research studies going on right now with facial nerve regeneration with stem cells with utilizing biodynamic modalities that help transfer electrical energy from one side of the face to the other, so there’s a lot of great research going on. I would say nothing is yet at a breakthrough where it’s clinically applicable, but my guess is, over the next five years to ten years, there will be breakthroughs coming along, especially with stem cells, especially with some of the other options that are available. So, there is hope; there are treatments that are coming, but right now nothing yet that’s out there.

Q: Does insurance ever cover surgery for damage from Bell’s palsy?

A: Great question; I get this all the time: Does insurance cover? Some insurance companies actually are excellent, and some programs are excellent, in coverage; some are terrible. We just don’t know. A lot of insurance companies will say, “Oh, this is cosmetic.” Of course it’s not cosmetic, you know, people have paralysis; they’ve gone through this whole physical issue. So, the only way we can tell, at least, is, first of all, see whether someone’s a candidate or not, and their insurance plan, and contact their insurance companies and see whether they cover for the surgery or not. There are usually some out-of-pocket costs. But, you know, the great thing about the new era, you know, in terms of traveling and going – I mean, and this is something that wasn’t available, really, ten, fifteen years ago, before this social media, Facebook, internet, and so forth, is, I think, getting the best possible treatments, and really trying to get – you know, this is a lifelong problem, trying to get the best possible answer that you can and treatment that you can.

Q: What are the permanent synkinesis treatment for long-term Bell’s patients?

A: If we see about a year to a year and a half after someone has had Bell’s palsy, I would say a year is the perfect timing; if they have synkinesis, I think there are options of treatment, and like we talked about, anywhere from surgery, Botox, physical therapy, and I think the combination of the three gives the best possible outcome, depending on the patient’s circumstance.

Q: I’ve heard so many times Botox helps with the eye getting smaller. Do you have to see someone who specializes in facial paralysis?

A: Botox for synkinesis is, at least the, kind of, the conceptual, where it needs to be injected, I do think someone who has experience with synkinesis needs to, kind of, come up with that plan. Now, once the plan is devised, then, I think, a facial plastic surgeon can probably do a good job, as long as they have some sort of roadmap.

That’s all the time we have. So, this has been really, really, really wonderful. We’ll try to actually do this a little bit more regularly. This is the first time I’ve done this Q&A on Facebook, so I’m excited, and I hope this was useful, and I look forward to our next time.

Thank you so much for coming on and it’s been wonderful. Have a great rest of your day.