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.
What Are the Signs of Synkinesis?
Common signs of synkinesis include:
- The eyes narrow when an individual smiles
- The cheek lifts when a person closes his or her eyes
- The neck muscle tightens when a person tries to whistle
- Facial twitching in the cheek and chin
- Facial muscles become tight, leading to facial pain and headaches
- A deeper cheek crease forms on the affected side of the face, causing the cheek to appear bulky
Many symptoms are associated with synkinesis, including:
- Increased tone in the facial muscles: Muscle tone may increase in the affected side of an individual’s face. In fact, a person likely will need to work two to three times harder to move these muscles than he or she would to move the muscles in the unaffected side of the face.
- Short, tight facial muscles: Facial muscles may become short and tight if they are overworked for an extended period of time. When this occurs, it may be difficult for an individual to move the muscles to display facial expressions.
- Linked facial movements: Linked facial movements will happen if a recovering facial nerve is poorly insulated. In this scenario, the message to move a particular muscle may be picked up by a nearby muscle, resulting in several simultaneous muscle movements (ie. when the patient smiles their eye narrows and closes too). Furthermore, linked facial movements may continue to occur after the facial nerve has fully recovered.
- Coordination problems: Coordinating facial movements can be exceedingly difficult, particularly for those who are recovering from a facial nerve issue.
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 pull 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 appropriately.
Other signs of facial synkinesis include:
- Dimpling in the chin
- Narrowing of the eye affected
- Increased facial muscle spasms
- Tightness of the neck bands and cheeks
Synkinesis often results in abnormal 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
Synkinesis cannot be prevented, however, there are something patients can to do minimize its effect after Bell’s palsy.
It is important to consult with an experienced occupational therapist or physical therapist who is specifically trained in treating facial nerve disorders. They 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:
- Synkinesis surgery
- Neuromuscular retraining (physical therapy)
- Botox (botulinum toxin) for synkinesis
Synkinesis treatment can be administered any time after the condition is diagnosed. Furthermore, a patient can use neuromuscular retraining, Botox or surgery to treat synkinesis even years after suffering from Bell’s palsy or facial paralysis.
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)
- Asymmetric Facelift
During your consultation, all options are discussed at length to determine if you are an appropriate candidate.
Botox for Synkinesis
Botox for synkinesis may be used in combination with selective neurolysis and/or facial neuromuscular therapy. It reduces muscle activity, minimizing the synkinesis effects 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)
Physical Therapy and Neuromuscular Retraining 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 physical therapy for synkinesis, 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. Our therapists may use both neuromuscular retraining and massage techniques to provide you with the best results.
Electrical stimulation increases overactive muscles, and as such, should not be used as part of neuromuscular training. Instead, tight overactive muscles are manually massaged and stretched. For example, patients are taught how to relax the effected eyelids 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.
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