FAQ of Bell’s Palsy and Facial Paralysis.
Featured from a Medscape interview with Director of the Facial Paralysis Institute, Dr. Babak Azizzadeh
Medscape: How are these patients normally treated?
Dr. Azizzadeh: The treatment of facial paralysis has significant variations depending on the cause, severity, duration and age of patients. Bell’s palsy, when initially diagnosed, needs to be treated immediately with high-dose steroids and antiviral medications (Valtrex or Famvir). However, it is paramount that the doctor who diagnoses “Bell’s palsy” rules out more serious conditions such as brain tumors, stroke, and head and neck cancer. Eye protection is also a key factor because most patients in early phases of the disease are unable to close their eyes and run a high risk of developing long-term corneal ulceration and blindness. Patients are encouraged to tape their eyes shut at night, use artificial tears and lubricate their eyes regularly.
Patients who present with long-standing facial palsy will require a more graduated treatment algorithm. There are three main treatment arms that we utilize: neuromuscular retraining, botulinum toxin (BOTOX, Dysport), and surgery. These options need to be tailored to each patient depending on various individual factors.
Medscape: What are the key investigations that should be performed on patients prior to surgery?
Dr. Azizzadeh: The underlying cause of facial paralysis needs to be uncovered. I’ve seen many patients in my practice that had been falsely diagnosed with “Bell’s Palsy” but turned out to have other more serious underlying conditions such as acoustic neuroma or parotid tumors. One should do imaging studies to make sure there’s no tumor or growths, an electromyopathy (EMG) to evaluate the nerve input and the muscle action. You want to see what’s really going on. You also want to see if there is any underlying tone to the facial muscles which will help us determine the appropriate operation for the patient.
Medscape: What are some of the key surgical challenges?
Dr. Azizzadeh: Every surgery is different. We customize the operation depending on the patient’s desires as well as age, cause, duration and severity of the paralysis. Most people have similar desires – improve functional deficits, create symmetry of their face, restore the smile mechanism and allow good closure of their eyes. In many patients who have fairly good facial movement, we will only be required to symmetrize their face with tendon transfers and facelift procedures. In other cases where patients have no movement, we will employ advanced surgical procedures using nerve and muscle transfers.
There are two key surgical procedures that truly benefit patients when used appropriately: 1) hypoglossal-facial nerve transfer; 2) cross-facial nerve grafting with gracilis free muscle graft. If patients are candidates for these operations, they have the best opportunity to obtain tone and spontaneous smile mechanism.
Medscape: Can you walk through some of the issues involved in nerve repair in the face?
Dr. Azizzadeh: When a patient has nerve injury when nerves are repaired or spontaneously regenerate (as is often the case in Bell’s Palsy), they often have no clue which muscle they have to innervate or activate. As a result, even under the best circumstances, patients will have uncoordinated facial movement that provides a very limited functional smile mechanism.
My research lab at Cedars-Sinai Regenerative Medical Institute is focused on studying growth factors and stem cells and seeing how we could force the nerve to grow to the appropriate location – but that’s a glimpse of the future, not what we can do now.
Medscape: Are there special considerations when it comes to transplanting nerves versus muscle when working on the face?
Dr. Azizzadeh: Nerve and muscle transfers from other parts of the body to the face is now a common procedure for restoring a spontaneous smile mechanism or muscle perform sural stage.
Medscape: What are the details of those stages?
Dr. Azizzadeh: In the first stage, we harvest the sural nerve from the ankle area and connect it to the normal facial nerve on the unaffected side. We allow the nerve to get neurotized or activated for 6 to 12 months. In the second stage, free muscle graft is utilized. The gracilis muscle with its nerve, artery and vein is harvested and anchored to the paralyzed side. The sural nerve is connected to the gracilis nerve (obturator nerve) and the artery and veins are hooked up to the facial artery and veins to allow blood supply to the muscle. When the patient smiles on the normal side, the gracilis muscle on the paralyzed side will get activated and move, thereby restoring the patient’s smile.
Medscape: That’s an interesting ‘work-around’. Are there others?
Dr. Azizzadeh: Many patients require just a modified/customized facelift to symmetrize the face and create more balance to the overall structure. We oftencombine this with blepharoplasty and browlifts to further improve symmetry. Medscape: It sounds like there is a certain amount of puzzle-solving when planning
Dr. Azizzadeh: The human face is a very special and unique part of our livelihood. It allows us to express emotions, communicate, develop relationships and interact with others in complex manners. Loss of facial expressions truly reduces our ability to socialize and advance in life. That is the true puzzle that we need to address.
Medscape: Are there differences in how you deal with young versus old patients?
Dr. Azizzadeh: Absolutely! Younger patients are better candidates for advanced surgical options such as cross facial nerve grafting with gracilis free flap. They have a higher success rate with these operations and have a better nerve regeneration ability.
Medscape: Is there extra training out there for plastic surgeons who wish to do these repairs?
Dr. Azizzadeh: I am a co-director of an American Academy of Facial Plastic & Reconstructive Surgery fellowship program and there are two to three other programs in the US that have in-depth training for facial plastic surgeons and plastic surgeons in this arena. My doors are always open for residents and visitors as well. Surgeons can also get more information from the Facial Paralysis Institute in Beverly Hills, California.
Medscape: Thanks for discussing this topic with Medscape today.
Dr. Azizzadeh often answers patient question on RealSelf.com. Below are some of his responses.
Q: Can Botox help with the residual effects of Bell’s palsy (upper lip unevenness)? I suffered from Bell’s palsy shortly after the birth of my second child. The case was severe, however, I’m now 80% recovered. Was looking into Botox and/or fillers to help alleviate the uneven appearance of the upper lip and chin, and was looking for a doctor in Southern California who was familiar with Bell’s palsy.
A: I regularly use Botox to help my Bell’s palsy patients in Los Angeles regain facial symmetry. It is a safe and effective way to improve appearance when performed by an expert. In a select number of patients, there may also be surgical treatments that complement Botox in helping patients regain their smile. Contact my office, The Facial Paralysis Institute, at (310) 657-2203 and we’d be happy to discuss this with you.
Q: Is there any hope for me to be cured from Bell’s Palsy after 17 years with it?
A: I’m sorry to hear of your struggle with Bell’s palsy. As a facial nerve expert, I commonly treat patients living with permanent facial paralysis. There are a variety of surgical treatment options, such as selective neurolysis, static suspension, or even facelift, but the best choice will depend on the individual. Contact my office for more information or to schedule a consultation. If you are not in the Los Angeles area, we can arrange a Skype consultation.
Q: I Have Just Experienced Bell’s Palsy of Right Side of my Face. Can my Face Come Back to Normal Look After Few Weeks?
A: You should see an ENT or neurology specialist to make sure there is no major issue lingering. Later, seek opinion from a facial paralysis expert. More than 90 percent of Bell’s palsy patients do return to normal.
Q: I’ve had Bell’s palsy for over 2 years. I’m about 90-95% recovered, but I can’t smile completely, just halfway. Please help.
A: A multidisciplinary approach is necessary in the treatment of facial paralysis. At the Facial Paralysis Institute in Beverly Hills, we utilize a systematic approach to reconstruct facial movement and restore a dynamic smile. For patients with facial paralysis and/or synkinesis who are unable to effectively smile after non-surgical treatment options, such as Botox and physical therapy, selective neurolysis is the most advanced treatment option. It’s a surgical procedure that involves the surgeon releasing the platysma muscle and decreasing nerve activity in the nerves that counteract the smile mechanism, so that the mouth can once again turn upward, restoring the patient’s ability to smile.
Q: Is a facelift possible after Bell’s palsy?
A: Yes. It’s actually a quite common procedure to even out the discrepancies between the two sides of the face. Just be sure to see a facial paralysis expert who can give you a customized procedure based on your individual features. At the Facial Paralysis Institute in Beverly Hills, the safety of the facial nerve during facelift surgery is a top priority.