Delayed Recovery

This information is suitable for anyone who has had their facial palsy for longer than 6 weeks with no sign or little sign of recovery. Below are answers to questions that are frequently asked in our support groups about the dormant period before the nerve starts to recover and when early signs of recovery are observed.

How long will it take for my face to recover?

Recovery time will depend on the type of facial nerve injury you have experienced. People with a delayed recovery beyond 6 weeks from the onset of their symptoms will most likely have a second-degree nerve injury. This occurs when the facial nerve has been exposed to a greater amount of swelling and compression is prolonged. The outer cover of the nerve remains intact but the nerve fibres inside are damaged and cannot receive essential nutrients and oxygen. Without these vital supplies the nerve starts to shrink and wither.

However, as the swelling subsides and the flow of nutrients and oxygen is restored, the facial nerve slowly starts to repair itself at the rate of one millimetre each day. This is why it takes longer to recover and most people with this type of nerve injury start to notice early signs of recovery at approximately 12 – 16 weeks following the onset of their symptoms.

It is important to note that when the nerve does recover your facial movements will not be so easy to control. This is because the nerve is highly excitable and often overworks. An unavoidable symptom of slow nerve recovery is synkinesis (involuntary or unwanted facial movements). People with second-degree nerve injury will develop some degree of synkinesis, for example, the affected eye closes or winks when you move your mouth. You can find more information about synkinesis here.

What can I do to make the nerve recover more quickly?

Unfortunately, there is very little you can do to hasten recovery, but the nerve will recover spontaneously if it can. What you need to think about is what happens to the facial muscles when the nerve is not working and how the facial nerve behaves once it regenerates.

What happens to the facial muscles when the nerve is not working?

You will see that the muscles on the affected side have lost their tone and shape, and can no longer move as before. The brain cannot see the face, as a result, the brain starts to neglect the affected side and the connection between the brain and the facial muscles fades. If this persists over a period of months, once the nerve does recover, it can make it hard for the brain to find the correct muscle/s required for a specific expression.

This is one of the reasons why facial massage is so important in the early months of recovery. Facial massage helps maintain the feeling of movement and keeps the brain in touch with the face so when nerve recovery happens, the brain remembers the location of the muscles. Find guidance on facial massage here.

What happens to the facial muscles when the nerve starts to recover?

The recovering facial nerve is highly excitable and often overworks.  It has lost its ability to know when to work and when to rest often sending out tiny electrical signals even though it should be resting. This results in muscles receiving too much electrical stimulation and very quickly the muscle tone changes from being floppy and low in muscle tone and becomes stiff and high in muscle tone, therefore it is more likely to increase in thickness and stiffness.

Stiff muscles struggle to relax effectively, so any muscles that develop stiffness will find it harder to shorten (contract) and relax. This is why learning how to relax your face is so important. You are teaching the nerve how to reduce its stimulation to the muscle, even when the muscles are not moving. Even the working side of your face benefits from relaxation, as it overworks to compensate for the weak side. It becomes dominant. The more the working side does the harder it becomes for the recovering side to regain its movement. Relaxation is therefore an important technique to learn. Doing this little and often throughout the day, even though the muscles are still weak, is an important part of your rehabilitation. Use our self-help relaxation videos to guide your facial relaxation.

When can I start practising facial expressions/movements?

Movement practices should only be started once your face has become more symmetrical at rest and when some small but consistent facial movements can be clearly seen. This is called the paretic stage of recovery. In addition, we recommend that you wait until you have reached the 12-week point in your recovery before starting any facial movement practices. Practising any facial movements without specialist help, or if performed incorrectly and/or started too soon, you can do more harm than good. In doing so you will increase the likelihood of developing synkinesis, and your muscles may become shortened, thicker, tight, and will lose their elasticity and ease of movement.

In an ideal world, you should only start practising facial expressions under the guidance of a specialist therapist experienced in the rehabilitation of facial palsy. You will require a bespoke programme of rehabilitation. Unfortunately, many people are unable to access this help at the time when it is most needed. If you do not have access to a specialist therapist or think you would benefit from additional guidance then visit our ‘management of paresis’ page which explains the when, why, and how of practising facial movements and talks more about the paretic stage of recovery.

What are the basic principles when practising movement exercises during the paretic stage of recovery?

• Do not start these exercises unless you are in the paretic stage of recovery, and it is at least 12 weeks since the onset of your facial palsy.
• Stop thinking about strengthening muscles and start thinking about producing small, delicate, but precise facial movements.
• If you are in any doubt about whether these exercises are appropriate for you then don’t do them. Continue with your facial massage, eye care advice, and relaxation exercises. This is the best way to minimise the development of synkinesis. Visit our ‘management of flaccid facial paralysis‘ for more guidance.
• If you decide these exercises are right for your stage of recovery you should only use very low effort, for example, 2/10 effort is sufficient to move the very light, delicate facial muscles.
• All movements should be slow, gentle, and symmetrical.
• The strong side always wants to take over but if when you smile your weak side can only move 1 mm then the strong side should only move 1 mm.
• Never practice asymmetric movements – the aim is to practice correct movement patterns which are symmetrical.
• Both sides must move together, the movements must start at the same time. The strong side must not move faster, further, or before the weak side.
• Movement practice takes great concentration and ideally should only be done under the guidance of a specially trained therapist. If you experience any synkinesis during your movement exercises, then discontinue until you get face-to-face advice.
• Only work for one minute on each of the basic movements demonstrated in the video on the link above (smile, lip rounding, eye closure), but you can do this several times throughout the day.

When and how can I get a referral to a specialist facial palsy service?

• You should ask your GP for a referral to a specialist facial palsy service if you have experienced little or no recovery from your facial palsy within the first 6 weeks. There is inevitably a waiting list for appointments so the sooner you are referred the better.
• Before approaching your GP for a specialist referral read the information on the following link: approaching your GP
• If you are unsure about details of your nearest specialist facial palsy service, you can contact Facial Palsy UK for specific guidance.

My affected eye keeps watering – can I stop using my eye lubrication?

Whilst eye closure is weak, and the blink is incomplete the affected eye will be vulnerable to dryness. A dry eye can become a watery eye. This is the body’s attempt to protect the eye from dryness but whilst you may experience excess tearing, the tears are very watery and lack the necessary nutrients and fats which help build up the protective tear film. It is therefore important to continue to use your eye lubricants even when you experience tearing and possibly increase the frequency of their use until the tearing stops.

Eye lubrication

Dry eye advice

The Psychosocial Consequences of Living with Facial Palsy

In addition to the questions above, it is important to emphasise the psychosocial impact of living with facial palsy for many weeks/months. Many people who contact Facial Palsy UK experience isolation, anxiety, low self-esteem, and depression. Find information, help and access to resources to help with the management of some of the psychological aspects of facial palsy here.

You can also ‘join our community’ and get access to virtual and face-to-face support groups. Join our community.