Facial Synkinesis Assessment and Treatment
Facial synkinesis refers to "simultaneous movement" that occurs after Bell's palsy or instances where the facial nerve has been cut and sewn back together. After Bell's palsy, the facial nerve fibers may be implanted into different muscles. Or, if the facial nerve has been resewn, the facial nerve fibers may reconnect to the wrong nerve group, leading to undesired and simultaneous facial movements.
Synkinesis results in an abnormal synchronization of facial movement. When this happen, involuntary facial movement may occur during voluntary movement of a different facial muscle group.
The images below demonstrate various degrees of synkinesis:
Facial synkinesis and full paralysis of the face are not the same. If a patient displays good facial tone and visible facial movement, he or she does not suffer from full facial paralysis. In this case, the patient's abnormal facial movements may be the result of synkinesis.
A synkinesis patient may display various facial muscle patterns. In many instances, a synkinesis patient's eyes may twitch or close when this individual laughs or smiles. Also, facial synkinesis may cause the corner of the mouth to move upward in patients who have regained their facial tone. The synkinetic (simultaneous) movement of muscles can cause the corner of the mouth (depressor anguli oris, platysma and mentalis muscles) to droop and elevate nearby muscles (zygomaticus major and minor). Therefore, it may be difficult for a synkinesis patient to smile.
Other signs of facial synkinesis include:
- Dimpling in the chin
- Narrowing of the eyes
- Increased facial muscle spasms
- Tightness of the neck bands and cheeks
Synkinesis often results in facial muscle patterns that can range in severity. As a result of Dr. Azizzadeh’s advancements in the field of facial reanimation surgery, patients now have several treatment options to choose from to improve their synkinesis.
How to Prevent Synkinesis
There are some things patients can do to prevent synkinesis from developing after Bell’s palsy. Today, Chevalier's method represents the most common technique to prevent synkinesis. This method serves as a form of "facial re-education" and encourages patients to maintain facial symmetry by:
- Keeping the face up when speaking
- Chewing food with the eyes open
- Avoiding gum
- Wearing sunglasses to prevent squinting
- Massaging the intraoral buccal area
- Stretching the eye muscles
Synkinesis prevention involves a proactive approach in the initial three to four months after injury or Bell's palsy. Several studies have indicated that electrical stimulation can increase the likelihood of synkinesis. However, those who understand how to perform synkinesis exercises and know the importance of synkinesis surgery can minimize the risk of synkinesis. It is important to consult with an experienced occupational therapist or physical therapist who can provide the patient with a specific set of exercises that are appropriate for their unique presentations of Bell’s palsy.
Synkinesis treatment is based on three modalities:
- Neuromuscular retraining (physical therapy)
- Botox (botulinum toxin) for synkinesis
- Synkinesis surgery
Synkinesis treatment can be administered any time after the condition is diagnosed. Furthermore, a patient can use neuromuscular retraining, Botox for synkinesis or synkinesis surgery to treat synkinesis several years after suffering from Bell's palsy or facial paralysis.
Physical Therapy for Synkinesis
Facial neuromuscular retraining emphasizes the coordination of appropriate facial muscle movements. With facial neuromuscular retraining, a synkinesis patient can limit abnormal movement patterns that otherwise would result in "auto-paralysis" of different facial muscle groups.
During facial neuromuscular retraining, the muscles that are contracting out of sequence will be identified. Then, a multi-step process is used to help a patient retrain the muscles at the neurological (brain) level.
Electrical stimulation increases overactive muscles, and as such, should not used as part of neuromuscular training. Instead, overactive muscles in the cheeks and neck are massaged and stretched, and patients are taught how to elevate the upper eyelids during eating to reduce eye synkinesis. In addition, neuromuscular retraining focuses on muscle re-coordination rather than stimulation, and synkinesis patients should not perform muscle-strengthening exercises as part of this treatment.
Typically, 90 percent of synkinesis exercises can be performed at home. A therapist will teach a patient how to perform synkinesis exercises properly and ensure that he or she fully understands the ins and outs of each exercise. The therapist may teach a patient how to perform mirror and video exercises as well.
Botox for Synkinesis
Botox for synkinesis may be used in combination with facial neuromuscular therapy. It reduces muscle activity, minimizing the dangers commonly associated with overactive and uncoordinated muscles.
The most common injection areas for Botox for synkinesis are:
- Eye muscles (orbicularis)
- Neck bands (platysma)
- Chin dimpling (mentalis)
Botox for synkinesis can also be used to improve facial symmetry by reducing the activity of certain muscles on the normal side of the face, such as:
- Lower lip depressors (depressor anguli oris)
- Crow's feet (orbicularis)
Before & After Botox for Synkinesis
Selective neurolysis is the most advanced surgery option for patients with synkinesis. Dr. Azizzadeh pioneered the selective neurolysis procedure for his patients who could not generate a proper smile due to their synkinesis and partial facial paralysis.
During selective neurolysis, Dr. Azizzadeh releases the platysma muscle, decreasing nerve activity that pulls the mouth downward and enabling the corners of the mouth to turn upward once again. Furthermore, selective neurolysis is a complex and intricate procedure, but the recovery period is rather minimal, similar to that of a facelift.
Other treatment options to address synkinesis include:
- Static suspension of the corners of the mouth
- Blepharoplasty (eyelid surgery)
During your consultation, all options are discussed at length to determine if you are an appropriate candidate.
Before & After Selective Neurolysis for Synkinesis
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