Exceptions to the normal path of facial nerve recovery
Generally, the pattern of recovery following injury to the facial nerve is the same for everyone regardless of cause. However, there are some exceptions which apply to the following groups:
- People born with facial palsy (congenital). Congenital facial palsy is where facial paralysis is present at birth. It can be caused by a variety of often complex syndromes, each requiring an individualised approach. Sometimes the facial nerves or muscles are underdeveloped, this can be mild or severe. Recovery in these cases may not be possible without surgical intervention. It should be noted that facial palsy can also occur during delivery 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 and weeks after birth. There is often a “wait and see” approach before more tests are carried out, to see if the palsy resolves naturally.
- People who have had their facial nerve completely severed/cut. This may be due to trauma, for example, head injuries. This can also happen during the course of surgery either to remove tumours or during some types of ear surgery (iatrogenic). In these instances there will be no natural recovery and treatment from health care professionals will be required to help restore some facial function.
- People who have undergone nerve grafts. These are delicate procedures with different time frames for recovery which require individualised rehabilitation programmes.
When is full facial nerve recovery possible?
Examples of causes where a full recovery from acquired facial palsy is possible are Bell’s palsy, Ramsay Hunt syndrome and Guillain-Barré syndrome, although all cases are different and the degree to which the facial nerve will recover is difficult to predict. Complete recovery cannot be guaranteed.
Please see comprehensive list of causes for more information.
See information about the three types of facial nerve injury.
What happens to the facial nerve when full recovery is expected?
The majority of people showing obvious signs of recovery within the first three weeks following their initial symptoms will quickly progress through the stages below:
- Flaccid stage: muscles are weak and floppy.
- Paretic stage: muscles start to regain their shape and tension and small spontaneous movements become visible.
- Full recovery is made within a few weeks following the onset of symptoms.
What happens when there is delayed recovery?
Excluding the exceptions in the first paragraph, all other forms of acquired facial paralysis, in which the person experiences a delayed recovery, will follow the trajectory described below. However, the length of time taken to travel through each stage will vary from person to person according to the degree of nerve damage.
- Flaccid stage
- Paretic stage
- Synkinetic stage
Immediately following the onset of facial paralysis, the facial muscles lose their tone or tension and become weak and floppy. Due to the effects of gravity on these weak and floppy muscles, they droop, for example, the eyebrow droops and rests heavily over the eye. Paralysis of the muscles that circle the eye means that it does not close or blink, and the eye becomes dry and sore eventually causing damage to the delicate eye surface. The corner of the mouth may droop making it difficult to speak, eat and drink.
If there has been no recovery at all after three weeks of treatment, or if you still cannot close your eye after 2-3 weeks following the onset of your symptoms, you should ask your GP to refer you to a clinician who specialises in the management of prolonged facial paralysis/palsy. Find out more about seeking a referral for specialist help.
As the nerves start to recover, the facial muscles start to regain their firmness and shape. The muscles can now work against the force of gravity and resume their normal length resulting in improved facial symmetry when the face is at rest. Facial expression may show signs of returning but this may be inconsistent, as facial muscles at this stage will tire quickly and the asymmetry may worsen over the course of the day. Some muscles begin to work before others: for example, your eye might start to close properly but your smile may still be weak. People will start to tell you how much better you are looking but your movements may still be very weak. There may be a tingling sensation in your face which can be a sign of nerve recovery – a therapist may test for this using Tinel’s sign. If you have any twitches you should always mention these to your healthcare professional as this can mean a number of things, some positive (in relation to recovery) and some negative (if signs of nerve compression). This is the paretic stage, or paresis.
If your recovery has been prolonged then the final stage of recovery will be the synkinetic stage or synkinesis. Synkinesis means the development of unwanted or involuntary movements. For example, on smiling the eye on the affected side may close involuntarily or the cheek may lift involuntarily when you close your eyes or lift your brow. The affected eye may seem smaller and the affected cheek may feel tight and stiff. Synkinesis can also cause headaches and pain in the neck due to short, tight muscles.
What parts of the body are affected by the facial nerve?
The facial nerve has five branches supplying each of the following areas:
What should you do if your face has not recovered?
- Seek help and advice to ensure that your eye is protected if your eye closure and blink has not fully recovered.
- Ask your GP to refer you to a physiotherapist or speech and language therapist for assessment and treatment. They should have specialist experience in the management and treatment of facial palsy.
- Do not attempt to carry out exercises without professional help as you may do more harm than good. Most people want to do something but trying too hard may lead to problems later on in your recovery. Refer to our self-help videos for safe ways you can help yourself.
- Try and relax and allow nature to take its course.
- Don’t be eager to force weak muscles to move. Allow them to recover in their own time whilst waiting for professional help.
- Advice from the internet, especially watching videos on treatment exercises, may be totally inappropriate for your individual case. Please seek professional help and guidance.
- If in doubt do nothing except simple massage and eye protection until you are assessed by a health care professional.
- Gentle facial massage is very good for the face. Using the pads of your fingers gently massage the brow, temples, cheek, chin and neck.
Remember every case of facial palsy is unique, so what works for one person may be totally inappropriate for another.
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Last reviewed: 14-02-2021 || Next review due: 08-06-2024