Selective Neurolysis (Neurectomy) and Myectomy

If you have synkinesis in your lower face, you may be offered a procedure to try and improve facial comfort, enhance the coordination of facial movement and reduce muscle tightness. This is referred to as Selective Neurolysis and Myectomy or Selective Neurectomy and Myomectomy or Neuromyectomy depending on what exactly is required and which hospital you attend. This page explains what’s involved in the procedure as well as outlining the benefits and risks.

What is it?

The procedure involves the permanent division of one or more branches of the facial nerve (selective neurectomy or neurolysis) and may be done in combination with the permanent division of one or more muscles of the face (myectomy).

Surgeons can identify the individual nerves that supply each facial muscle often using a nerve stimulator, and remove part of the nerve to the muscle that is causing synkinesis.

Synkinesis in your lower face causes a downward pull against the mid-face muscles which you use to smile. Cutting the nerve to the platysma (neck muscle) and/or the depressor muscle of the lip allows the smile muscles (elevators) to work more effectively, which helps you to smile more easily with reduced effort and synkinesis. It can also decrease discomfort in the neck and lower face by reducing muscle tightness.

Note: There is also the option of a highly selective neurectomy to improve synkinesis around the eye but this is less commonplace.

Who is a suitable candidate?

The surgery is usually offered to patients experiencing synkinesis in the lower face particularly those with lower lip asymmetry, where alternative treatments such as physical therapy and/or Botulinum toxin injections have not been effective enough or long-lasting.

What are the risks?

As with any surgery, there are risks associated with this procedure.

Facial Injury: Injury to adjacent muscles, nerves, or blood vessels may occur during the surgery.

Under-correction: Surgeons tend to be more conservative when performing a selective neurolysis to avoid losing function, so there is a risk of under-correction. In these cases, a second procedure or further Botulinum toxin treatment may be needed.

Overcorrection: There is also the risk of overcorrection, which could result in new issues arising.

Loss of function: Cutting nerves and muscles can lead to loss of facial functions. As mentioned above, surgeons will usually err on the side of caution, but the risk is still there.

Weakening of the face: The procedure is designed to improve symmetry and comfort but this may come at the expense of movement. You may find that you experience a reduction in movement when smiling.

Infection: As with all operations, there is a risk of infection. If you experience increasing pain, redness and fluid discharge from the wound and a high temperature, you should contact your medical team immediately.

Scars: You will have a scar where the incision is made. The scar will become red and raised, but over the coming two years it will continue to soften and flatten. On occasions, scars can remain thick and raised and in this situation, the surgeon will offer you some treatments to try and reduce this. In all cases, you must massage the scar a couple of times a day once the wound has healed to help soften the scar. This should be continued for two years.

What are the alternatives?

Alternative surgeries are available which can be split into two main categories; those that improve the symmetry of your face at rest (static procedures) and those that improve the position at rest and can produce movement of the face to express emotion (dynamic procedures). If you do not feel that Selective Neurolysis is right for you, then you can discuss other options with your surgeon or medical team.

Botulinum toxin injections also have a similar if less permanent effect and this option should be explored before surgery.

Specialist facial therapy under expert guidance can also be very helpful in the treatment of synkinesis.

How do I prepare for a Selective Neurolysis and Myectomy?

Your medical team will ensure that you are physically and psychologically ready for the surgery, and the post-op rehabilitation. They will carry out a series of assessments before your operation.

If you decide to go ahead with the surgery, your facial therapist will start you on a pre-operative program of stretches. You should have been through extensive facial therapy including massage, stretching and neuromuscular retraining before being offered the surgery, and you will need to continue with daily facial stretches and exercises that have been provided by your therapist.

You will also have had several sessions of chemodenervation (Botulinum Toxin). This mimics the effects of permanently cutting the nerve and helps to assess the effect the procedure will have on the muscles.

What does the surgery involve?

The procedure is commonly performed under general anaesthetic. The surgeon will make an incision in front of your ear to separate the muscle, fat and skin, and to access the nerve branches. The surgeon will then identify which muscles the nerve branches control using a nerve stimulator. They will then remove a section of the nerve and if indicated, a strip of the platysma muscle to break the connection between the nerve and muscle.

The surgery will be completed in around three hours in theatre as the nerve location procedure is very intricate work. If the surgery is carried out in conjunction with other procedures then time scales will vary.

Will I feel any pain or discomfort?

There will be some pain, as you would expect from any medical procedure, and you will be provided with pain relief medication to combat this. You may find that the area of skin that has been lifted and separated from muscle during the surgery feels numb for a time.

What happens after the surgery?

Most people will stay in hospital for one day after surgery, and you will have bandages, sutures and a wound drain. Most people are able to get up and walk around on the same day. Once you are deemed stable and have had your drain removed, you will be able to go home.

There will be some swelling which will peak around three to four days after your procedure. You will be given a face mask to wear at home and you should keep this on day and night for the first two weeks, although it’s fine to remove it for eating and personal care. It also helps to sleep with your head raised on pillows and to apply post-op arnica ointment.

You must not massage your neck until you’ve had a post-operative follow-up appointment with your facial therapist.

When will I have a follow-up appointment?

You will have an appointment two weeks after your surgery where your wounds will be checked and your stitches removed.

What is the therapy program after my operation?

Your facial therapy will resume around two to four weeks after your operation. The surgery on its own will not lead to improvements in your facial expressions. Now that the smile muscles have been freed up, you can continue the neuromuscular training you have been taught to improve movements and expressions. You’ll need to relearn how your face moves and practice those movements. Your facial therapist can help with this as it is the most important part of the process. You will have monthly therapy sessions to help you, which will focus on learning low effort facial movements. These will be done in conjunction with any other therapy or chemodenervation that you may be having for other parts of your face.

How long will the effects of this surgery last?

This operation is designed to have a permanent effect on your face. It is a relatively new procedure and there is no long-term evidence of whether the nerve connection will re-establish itself, but in most cases, the body is unlikely to re-grow nerve branches to the platysma and lip depressor muscles. The procedure, along with therapy, should therefore result in a lasting improvement to your smile and facial comfort as well as reduced synkinesis.

What should I do if I have any concerns?

If you have any concerns, you should contact your surgical team or the ward that you were admitted to during your stay. They will then be able to give you further advice on what to do and whether they need to see you back at the hospital or not.

Frequently asked questions

I have been told I have to stop having Botox ahead of Selective Neurolysis (Neurectomy) and Myectomy surgery, why is this?

It is important that there is no residual botulinum toxin in your facial muscles ahead of this kind of surgery. This is primarily because the botulinum toxin can reduce the effectiveness of the stimulator used in surgery to identify which nerve branches are causing your synkinesis, resulting in your synkinesis not being reduced as effectively. In addition, having botulinum toxin in your facial muscles prior to surgery can make it hard for you to assess how much the surgery has improved your synkinesis.