When the facial nerve stops working, half the face loses movement: the eye does not close, the lip droops and the smile disappears on that side. Facial reanimation sets out to restore function, always starting with the eye.
Facial paralysis can follow a Bell's palsy that did not recover, a tumour of the nerve or its removal in surgery, trauma, an infection, or it can be present from birth, as in Möbius syndrome. What the person experiences is always similar: they cannot close the eye, liquid spills 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.
There is a hierarchy that is not up for debate: the eye first. An eye that does not close dries out, ulcerates and can lose vision, and that is the only part of the condition that threatens something irreversible in the short term. It is protected from day one with drops, ointment and taping at night, and it is resolved surgically with straightforward procedures — a weight in the upper lid, tightening the lower lid — that change the patient's life in a single operation. The smile comes afterwards, and it is far larger surgery.
It usually helps when there is
- Facial paralysis that has not recovered after six to twelve months.
- Being unable to close the eye, with dryness or damage to the cornea.
- Paralysis after removal of a tumour or after trauma.
- Congenital facial paralysis, including Möbius syndrome.
- Longer-term effects: synkinesis, contracture or marked asymmetry at rest.
Worth discussing first if
- Recent paralysis that may still recover on its own: you wait and monitor.
- An active tumour of the facial nerve awaiting cancer treatment.
- No donor site available for a nerve or muscle transfer.
- Conditions that rule out prolonged microsurgery.
- Expecting complete symmetry and an identical smile.
None of these rules the procedure out on its own; all of them change the conversation.
What can be done
The technique is decided by the time elapsed and by the state of the nerve and the muscle.
Eye protection
The first thing and the most rewarding. A gold or platinum weight in the upper lid and tightening of the lower one. Short surgery, immediate change.
Nerve surgery
Direct repair, nerve graft or transfer from the masseteric or hypoglossal nerve. Only if the facial muscle is still alive.
New muscle
When the facial muscle has already died: microsurgical gracilis transplant, or temporalis transfer. It gives movement back to the smile.
The muscle has an expiry date
The technical decision rests on a biological fact: a muscle that has gone too long without a nerve wastes away and is replaced by fibrous tissue irreversibly. That window sits at roughly eighteen to twenty-four months. Within it, it still makes sense to bring a nerve to the muscle already in the face — with a nerve graft or a transfer; outside it, that muscle will no longer respond however much nerve is connected to it, and new muscle has to be brought from elsewhere in the body.
That is why coming in early is not a formality: it changes the surgery that can be offered. The option within the window is less invasive and gives a more natural smile; the one outside it is a microsurgical transplant, long surgery that needs several months before the muscle starts to move.
The assessment includes electromyography to find out whether the muscle is still alive, as well as the clinical examination. And the result is measured on three levels that are achieved in order and not always completely: symmetry at rest, eye closure and a smile with movement. Recovering a spontaneous, symmetrical expression is the hardest of all.
What the process is like
First the urgent part is protected, then the movement is planned.
Assessment
Cause, time elapsed, examination by zones and electromyography to find out whether the facial muscle is still alive. Ophthalmological assessment.
Eye protection
Immediate measures and, if needed, eyelid surgery. It is the priority and does not wait for the definitive plan.
Reanimation surgery
Nerve graft or transfer if the muscle is alive; microsurgical muscle transplant if it is not. It may require two stages.
Rehabilitation
Facial therapy over months to learn to use the new movement. Without it, only half the benefit of the surgery is realised.
What to expect
Movement does not appear on waking from surgery: the nerve takes months to grow.
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Weeks 1 to 3
Swelling and wound care. If eyelid surgery was done, eye closure improves immediately.
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Months 1 to 3
Still no movement with nerve surgery. Facial therapy begins. It is the phase that demands most patience.
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Months 4 to 9
The first movements appear, weak and poorly controlled. Therapy teaches how to direct them.
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Months 12 to 24
Final result. Whether symmetry adjustments are needed is assessed, and in some cases botulinum toxin on the healthy side.
Risks, and what is not promised
Infection, haematoma, scarring, insufficient or absent movement despite correct surgery, residual asymmetry and the need for touch-ups. With nerve transfers there may be weakness at the donor site — of the tongue or of chewing, depending on the nerve used — and synkinesis, involuntary movements that appear when another part of the face moves.
With a microsurgical muscle transplant: partial or total loss of the transplanted muscle from failure of the vascular connection, which is the most serious complication and forces the plan to be reconsidered; too much or too little volume in the cheek; and a scar on the donor thigh.
A symmetrical face is not promised, nor a smile identical to the other side, and still less a spontaneous expression. What is sought is to protect the eye, improve symmetry at rest and recover a voluntary movement that allows a recognisable smile: it is a significant improvement, not a restoration. These risks are reduced by early assessment, a technique chosen according to the time elapsed and consistent rehabilitation. They are not eliminated. The ones that apply to your case are set down in writing in the informed consent.
The information on this page is for guidance and does not replace an in-person medical consultation. Medical practice is an obligation of means, not of result.
The questions we are asked most
It depends how long the paralysis has lasted. A facial muscle without a nerve wastes away irreversibly within about eighteen to twenty-four months.
Within that period a nerve can be brought to the muscle already in the face. Beyond it, new muscle has to be brought from the thigh. Both options exist, but the first is less invasive and more natural.
The eye, always. An eye that does not close dries out and can ulcerate the cornea and lose vision, and it is the only part of the condition that threatens something irreversible in the short term.
It is protected from day one with drops and taping at night, and resolved with short surgery that greatly improves quality of life. The smile comes afterwards.
Not on leaving theatre. With nerve surgery, the first movements appear between four and nine months, because the nerve has to grow as far as the muscle.
The result finishes settling between twelve and twenty-four months, and facial therapy during that period is part of the treatment, not an add-on.
Not completely. What is sought is symmetry at rest, eye closure and a recognisable voluntary smile, and that is achieved in most cases.
A spontaneous expression identical to the healthy side is not promised: it is the hardest thing to recover and frequently it is not fully achieved.
Question not answered here? There are more answers in the frequently asked questions.
