Facial palsy: the eye comes first, and there is a window of time

When the facial nerve stops working, half the face loses movement: the eye will not close, the lip drops and the smile disappears on that side.

It may follow a Bell's palsy that did not recover, a tumour of the nerve or its removal during surgery, trauma, an infection, or be present from birth. What the person experiences is always much the same: they cannot close the eye, liquid runs from the mouth when they drink, food collects in the cheek, speech drags and they have stopped smiling in photographs.

The social impact is enormous and usually far greater than those around them realise.

The order is not up for debate: the eye first

An eye that will not close dries, ulcerates and can lose sight. It is the only part of the picture that threatens something irreversible in the short term, and that is why it comes first always, ahead of any consideration of the smile or of symmetry.

From day one, without waiting for any surgery: artificial tears frequently during the day, ointment and taping the eye closed at night, and review by ophthalmology. This is not a minor stopgap: it is what prevents a corneal ulcer.

Surgically it is addressed with simple procedures — a weight in the upper lid, tightening the lower lid — that change the patient's life in a single operation, under local anaesthesia and as a day case. The smile comes later, and it is a far bigger operation.

Protecting the eye is cheap, quick and urgent. Reanimating the smile is complex, slow and can wait. The order is never reversed.

The window of time

The first eighteen to twenty-four months decide which surgical options exist afterwards, and this is the part most often wasted through not knowing.

The reason is that a muscle which has lost its nerve does not wait indefinitely: over the months it wastes and stops being recoverable. While it remains viable, a nerve can be given back to it and the patient's own muscle moves again. Once it is not, muscle has to be brought from elsewhere in the body, which is a far larger operation.

Both are done and both work. But they are not the same, and which one applies depends on how much time has passed.

Hence a concrete recommendation: if it has been more than six months without recovery, be seen now, even if you were told to wait. Waiting makes sense in the first months of a Bell's palsy, because many recover on their own. Waiting two years makes none.

What can be done

• For the eye: an eyelid weight, tightening of the lower lid, and conservative care from day one.
• For symmetry at rest: suspensions that reposition the corner of the mouth and the cheek, and procedures on the healthy side to balance it.
• For the smile: nerve transfers while the muscle is still viable, or free muscle transfer once it is not.
• Rehabilitation, which accompanies all of the above and is not optional.

What is not promised

A symmetrical face is not promised, nor a smile identical to the other side, and still less a spontaneous expression. The aim is to protect the eye, improve symmetry at rest and recover a voluntary movement that allows a recognisable smile.

That is a significant improvement, not a restoration. And for someone who has spent years avoiding photographs, that distinction matters less than it seems from the outside.