Congenital vs Acquired Facial Palsy

What is the difference between Congenital versus Acquired Facial Palsy?

Where facial paralysis is present at birth it is known as congenital facial palsy. Sometimes the facial nerve and/or muscles fail to develop properly in the womb, or the facial palsy may be caused by rare developmental syndromes or conditions each requiring an individualised approach. In most cases where the nerve has failed to develop normally in the womb, the resulting weakness or paralysis of the facial muscles is permanent. In these circumstances the nerve is not injured it is absent or poorly developed. Hence there is no possibility of nerve recovery, and the absence of normal muscle tone and movement will not resolve. The facial asymmetry can only be addressed with surgery where appropriate. Facial palsy can also occur when a baby is delivered often due to pressure or trauma to the facial nerve. In these cases, there may be some facial nerve recovery within the first few days or weeks after birth. There is often a “wait and see” approach before more tests are carried out, to see if the palsy resolves naturally.

In acquired facial palsy the circumstances are different. Acquired facial palsy occurs when a previously normal functioning facial nerve is injured either through disease, infection, and/or trauma. An injured facial nerve can recover provided it has not been cut. Please see the links below for the different types of nerve injury and to learn more about how the facial nerve recovers:

The three types of facial nerve injury

Facial nerve recovery

When are stretches for the affected side of the face indicated?

• Stretches on the affected side of the face are appropriate for people living with an acquired facial palsy but only when the facial muscles are tight and feel stiff, thicker than normal and contracted (shortened).
• Stretches to the affected side of the face should not be done during the flaccid stage of recovery when the muscles are weak and floppy.
• Stretches to the affected sides of the face should be avoided if you have a congenital facial palsy. This is because the muscle tone is low, and the muscles are floppy (flaccid) with no chance of recovery.  Stretching floppy facial muscles will eventually lengthen them and make the asymmetry more obvious and make any corrective surgery more difficult.

When are stretches to the unaffected/working side of the face indicated?

To prevent harm, it is recommended that stretches to the unaffected side should only be done by people with acquired facial palsy. This is because the recovering facial nerve follows a predictable journey. The only exception would be if you are undergoing any facial surgery, in which case you should get specialist advice from your surgeon and facial therapy team before doing any facial exercises.

Why should people with congenital facial palsy avoid stretches to the unaffected/working side of the face?

In principle, it should be safe to stretch the working side of the face for those with congenital facial palsy but as these presentations can be complex it is safer to seek professional advice beforehand. This is because people with congenital facial palsy may have more complex presentations or the symptoms go beyond the facial asymmetry itself. Or the person may be undergoing a series of surgeries which means that you should seek specialist advice from your surgeon and facial therapy team. If you have a congenital facial palsy, you must be seen by a specialist facial palsy service for a bespoke home exercise programme which you can safely carry out and stretches to the working side of the face may well be part of that programme.

When should stretches to the unaffected/working side of the face be carried out?

It may seem odd thinking about doing anything to the unaffected/working side but during the flaccid stage of recovery when the affected facial muscles are weak and floppy the working side can start to work harder to compensate for the lack of movement on the weak side. The exaggerated facial expressions start to pull the weak muscle across the midline of the face making the asymmetry more obvious. Stretches to the working side of the face are particularly important when the muscles on the affected side of the face are weak and immobile and should continue until movement has returned or until they have become strong enough to offer resistance.

It is important to stretch the working side of the face because:

• Dominance of the working side can also compound the problem of neglect. The brain can start to neglect the affected side of the face because it is not moving, so the working side becomes the focus of attention. By stretching the strong side and relaxing the muscles which are over working, it is possible to minimise the degree of neglect.
• Stretching and relaxing the working side of the face means you are maximising your potential to recover by minimising the brain’s tendency to neglect the weak side of the face, promoting a better resting symmetry, and promoting better symmetry whilst speaking, eating, and drinking.

For further explanation and a demonstration of stretches for the unaffected/working side of the face please follow the link below to the video ‘Stretches for the Strong Side’:

Management of flaccid paralysis – stretches for the strong side

Why is facial massage important?

Facial massage is important and should be done following the technique described and demonstrated on the ‘massage’ video on the link below:

Management of flaccid paralysis – massage

Facial massage to both sides of the face can help:

• To prevent immobile muscles from becoming stiff through lack of use.
• To maintain the feeling of movement so the brain keeps in contact with immobile muscles and remembers their location. This is especially important if recovery is delayed, as it may be several months before facial movement returns. This is long enough for the brain to forget the location of the correct muscle needed for a given movement.
• Using the pads of your fingers to massage both sides of your face gives you information about how muscles feel. Are they loose and easy to move or are they stiff and resistant to being mobilised? Are there areas of tenderness? Can you notice any difference between the working and non-working side of the face. Can you notice any improvement?
• To promote facial relaxation which is important for both sides of the face.
• Reduce pain.
• Reduce exaggerated movements on the non-working side of the face along with relaxation exercises.
• To improve circulation in the muscles especially if you have been asked to start a programme of stretches. Massaging before stretching can make stretching muscles more comfortable.

Can people with congenital facial palsy massage their face?

The complexity of some types of congenital facial palsy make it difficult to make general rules about when and for whom facial massage is appropriate. In principle, it should be perfectly safe for people with congenital facial palsy to massage both sides of their face. The exceptions are:

• If you have been told not to do so by your specialist.
• If you are undergoing surgery or a series of facial surgeries including any surgery to eye muscles.
• If the muscles around the eye are very loose and floppy and the lower eyelid is drooping and/or turning outwards exposing the eyeball.

The potential benefits of facial massage to the working side in combination with stretches (if stretches have been recommended) are:

• Aid in the reduction of exaggerated movements.
• Aid relaxation.
• Massaging before stretching the working side may make this more comfortable and easier to do.

Congenital facial palsy is the result of poor or absent development of the facial nerve/muscles. It is not an injury to the nerve which may recover but a static condition and surgery to address the asymmetry may be the only option.  The benefits of massage to the affected side may therefore be limited and in some cases not recommended.  Always seek specialist advice before carrying out any facial stretches and or massage.