How a Facial Plastic Surgeon Treats Bell’s Palsy

Some of our newsletter readers have asked us for resources on Bell’s palsy, a facial paralysis condition that has also affected several of our friends over the years. To learn more, I interviewed Joshua D. Rosenberg, MD, who is an assistant professor and cochief of the division of facial plastic and reconstructive surgery at Mount Sinai Health System, and the doctor who treated one of my colleagues.

WHAT IS BELL’S PALSY AND HOW IS IT DIAGNOSED?

Bell’s palsy is the most common cause of facial paralysis, and it affects about 40,000 people in the US every year. It’s typically when one side of the face is paralyzed, without a clear explanation of why. Facial paralysis can occur for a variety of reasons, like brain or salivary gland tumors, facial traumas, car accidents, or lacerations to the face, among others. We diagnose Bell’s palsy by excluding all the other possible causes.

It usually goes something like this: A patient will notice that one side of their face isn’t moving as it usually does—they can’t close one eye or smile fully, for example. They can become aware of this when they wake up in the morning and see it in the mirror, when they feel a slight discomfort on one side of the face during the middle of the day, or when a coworker (or someone else) points it out to them.

Most people will either call their doctor or go to the emergency room (I strongly advise seeking medical care from the ER, your primary doctor, or any other qualified health professional if you notice facial paralysis), where they get a variety of tests to make sure they’re not having a stroke or experiencing paralysis due to any other known reasons. Once all other causes are eliminated, there’s a presumptive diagnosis of Bell’s palsy—there are no blood or imaging tests available that confirm you have it.

WHAT CAUSES BELL’S PALSY?

We don’t fully understand what causes Bell’s palsy. The most common theory is viral reactivation, where a virus that is dormant in the body gets reactivated for unknown reasons, causing inflammation and swelling of certain nerves.

With Bell’s palsy, it’s hypothesized that a viral reactivation occurs in the facial nerve, which runs from the brain to the face through a very small bony canal in the temporal bone, on the side of your head at the base of your skull. Because that canal is very small, when the nerve swells (due to inflammation caused by the viral reactivation), it pushes up against the canal, compressing itself and limiting blood flow. This damages the nerve and, as a result, limits the movement of the facial muscles that the nerve controls.

Once that swelling comes down, the nerve can heal. But once there’s damage, there’s often some permanent dysfunction, ranging from minimal to severe.

CAN YOU RECOVER FROM BELL’S PALSY?

About 80 percent of people with Bell’s palsy recover without severe long-term effects. Their facial expressions may not completely go back to normal (a 100 percent recovery), but any slight asymmetry or weakness on one side compared to the other is so small it’s considered subclinical—it doesn’t significantly affect their daily lives or have substantial consequences for them.

WHAT’S DIFFERENT ABOUT BELL’S PALSY DURING PREGNANCY?

Pregnant women are more likely to get Bell’s palsy, and they may be less likely to recover from it.

Rates of Bell’s palsy during pregnancy are slightly higher than in the general population—pregnant women are about three times more likely to get Bell’s palsy than others, and if they do, it’s usually during the third trimester. The data is limited, but right now it seems like the recovery rates are lower in pregnant women—about 50 to 60 percent of pregnant women recover (compared to 80 percent of the general population). The other 40 to 50 percent have long-term effects.

WHAT CAUSES BELL’S PALSY IN PREGNANCY?

We don’t know why the rates are higher in pregnant women (or why the recovery rate is lower) because we don’t fully understand why anyone—pregnant or not—gets Bell’s palsy. But it’s likely due to changes in hormones.

We think that hormonal changes and immunosuppression during pregnancy may predispose some pregnant women to having viral reactivation, although we don’t have proof of this. Other possible causes are because of the increased fluid retention during pregnancy. This can lead to swelling anywhere in the body, including in areas around the facial nerve, which can put pressure on the nerve, prevent blood flow, and eventually cause paralysis. For similar reasons, higher blood pressure during pregnancy could also contribute to the higher rates of Bell’s palsy during pregnancy.

WHAT ARE THE SHORT-TERM TREATMENT OPTIONS FOR BELL’S PALSY?

If you, unfortunately, get Bell’s palsy while you’re pregnant, it’s important to understand treatment options and their effectiveness. There are a couple of medications that we recommend for initial treatment, followed by supportive care.

Note: If you’re diagnosed with Bell’s palsy while you’re pregnant, it’s important that your ob-gyn is involved in determining your medical treatment—some medications are safer for pregnancy than others.

Medications

When it comes to medical treatments, we generally recommend a high dose of steroids—typically a corticosteroid like prednisone—with dosages that taper off over time. But steroids can affect the health of your pregnancy by increasing blood sugar, which can be particularly concerning for women who have pregnancy-related diabetes. This is an example of why it’s important that your ob-gyn be involved in your treatment process.

Antiviral medications, like acyclovir or valacyclovir, are also commonly used.

Eye Protection

Even if you’re prescribed medications, they don’t immediately cure facial paralysis. The inability to move your face will likely continue for at least a couple of weeks after you begin taking the medication. This creates a challenge for you socially—because you’re not able to smile—and medically because the paralysis often affects your ability to completely close one (or both) of your eyes, which increases the risk of dry eye, a scratch on the cornea, or an eye infection. Any of these can lead to permanent eye scarring and, in severe cases, loss of vision.

To help, patients can use eye drops and ointment to keep the eye moist, lightly tape the eye shut while sleeping, and wear glasses to protect their eyes when they’re outside, especially if they’re in a dusty environment, like a park or beach, where tiny particles are more likely to get into your eye. And visiting an ophthalmologist during your recovery, for preventive measures, is ideal to monitor the health of your eyes.

WHAT ARE THE LONG-TERM TREATMENT OPTIONS FOR BELL’S PALSY?

With medications and eye protection, most patients get better after a few weeks. For those who don’t, the options become much more varied and the chances of recovery are more complex. The most common long-term complications from Bell’s palsy include loss of fine motor movement in the face, chronic spasms on the affected side of the face, and discoordinated movement (e.g., blink your eye and the corner of your mouth moves at the same time, or smile and your eye also closes). These affect a person’s ability to broadly smile, and they’ll often notice that when they try, their entire face intensely tightens and clamps down.

It’s important for patients to understand that these long-term symptoms can be very hard to treat and that there are no set guidelines for managing them, but certain interventions can help. In addition to being aware of the different treatment options, patients should know that their effectiveness is usually additive—one type of treatment may help, but the patients who get the best results are the ones who combine them.

Physical Therapy

Working with a physical therapist who is trained in effective facial retraining techniques is essential. Most physical therapists are not well-versed in this—I’ve seen many patients who’ve done physical therapy with very well-meaning therapists who simply don’t know how to do this successfully. And the patient doesn’t benefit from the therapy.

There are no specific certifications to look out for, but if your physical therapist’s recovery plan includes biofeedback, it’s a good sign that they know what they’re doing. If you contact a plastic surgeon or a head and neck surgeon, they can usually provide good recommendations. (Note: If the physical therapist is using a TENS [transcutaneous electrical nerve stimulation] device—a method that delivers electrical pulses to the skin using electrodes—then they’re probably not up-to-date with the current research, and working with them may not be helpful for your recovery. There’s conflicting evidence on the effectiveness of this method for Bell’s palsy, and some say it could make things worse.)

When it comes to the recovery time with physical therapy, I always warn patients that it’s not short. It’s years of work to get the most benefits out of therapy. It includes exercises that must be incorporated into your daily routine. No one’s excited to hear that, but the patients who are consistent with it see real improvements.

Botox

Most people know Botox as a cosmetic treatment, but it’s a medication that’s derived from botulinum toxin, a paralytic agent. To treat spasms, we use Botox to selectively paralyze or relax certain muscles on the affected side of the face. It helps to loosen up facial muscles and reduce the spasmic movements that come with long-term effects of Bell’s palsy. Sometimes patients see an improvement in their smile from it, too.

For Bell’s palsy treatment, I recommend seeing either a plastic or facial plastic surgeon who’s experienced in treating facial paralysis—you’re more likely to get a better outcome.

Surgery

Surgery can improve facial movement and the quality of life for some patients, but it doesn’t completely restore the face to its original state. Which surgery you get and when is determined on an individual basis. The first step is to determine whether surgery can actually help you. If so, there are a few options.

• Selective neurolysis: This is when we do a facelift-type incision; map out all the branches of the facial nerve, a major nerve that controls facial movement; and then cut certain branches to help reduce spasms in the areas that are preventing the person from fully smiling.
• Selective myectomy: For this surgery, we cut some of the muscles that are dragging down the smile and leave other muscles intact to help the smile become bigger and broader.
• Blepharoplasty: This procedure is for the eyelids. We perform blepharoplasties and brow lifts to create more symmetry.
• Nerve transfer: A surgery that involves connecting facial nerves to a different motor nerve (i.e., a type of nerve that creates muscle movement) in the face.
• Muscle transfer: For severe cases or patients who really want a bigger smile, we can do muscle transfers where we transplant a muscle (usually from the leg) up to the face to bring in new muscles to create a broader smile. We connect those muscles to new arteries and veins to create blood flow and attach them to nerves in your face to repower them.

This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of goop.