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Physician Resource

Rebuilding Smiles: UVA Leads Work to Create Natural Facial Expressions After Facial Paralysis

For someone with facial paralysis, a smile can mean everything.

“Facial expressions are an innate part of being human,” says Samuel Oyer, MD. “When someone smiles with half their face, people unconsciously respond to them differently. When you lose that important way of communicating with the world, it affects you profoundly.”

UVA Health’s facial reanimation program gives patients with facial paralysis the ability to create more natural facial expressions. It’s one of just a handful of programs in the United States offering the full spectrum of facial reanimation treatments, including new advancements in surgical techniques, specialized physical therapy, and targeted Botox injections. It also serves as a leader in improving techniques, training providers, standardizing outcomes measurements, and educating the medical community about available treatments.

Advanced Surgical Procedures Addressing Synkinesis

Patients who do not regain full facial nerve function after Bell’s palsy, trauma, or acoustic tumor treatment sometimes develop synkinesis.

“Their face can pull and tighten on the side that was paralyzed, causing muscular spasm,” Oyer says. “When they try to move their mouth, their eye also closes, or different parts of the face move together.”

In cases where the facial nerves are injured but still intact, selective facial neurectomy helps patients achieve more natural facial movements. The surgical procedure includes mapping facial nerves with an electrical current and observing which muscle each nerve branch activates.

“As the nerves recover, they get cross-wired and aren’t always predictable,” Oyer explains. “We look at each patient to understand which nerves are causing motions we want, like a smile, and which are causing unwanted movements, like too much lip pucker or moving the mouth sideways or down.”

Oyer then selectively cuts the segments of nerves causing the unwanted movements.

Oyer can also stop unwanted movements with myectomy by selectively cutting muscles responsible for unwanted movement, such as the platysma muscle, which can pull the corner of the mouth down.

“When a person with synkinesis smiles, the frown muscle may be activated so the smile can’t show through,” he says. “These procedures make the facial muscles we want to activate work stronger with less opposition from muscles we don’t want to work.”

The procedures offer long-lasting and sometimes permanent results compared to targeted Botox injections, which offer improvement for just 3-4 months.

“We’ve seen a lot of improvement in patients’ ability to show teeth when they smile, which is often one of their big goals,” Oyer says. “When they smile, the unaffected side shows teeth while the lips are closed tight on the other side because the muscle is tight.”

Oyer offers myectomy as an in-office procedure and neurectomy as an outpatient procedure.

Improving Surgical Techniques to Power Smiles

When surgery can't reactivate muscles and nerves, Oyer uses a gracilis free flap to recreate a smile for people with long-term facial paralysis.

“We bring in a portion of the gracilis muscle and do a free flap to connect it to the lip and cheek bone,” Oyer says. “We recreate a smile vector that is symmetrical to the other side if the paralysis is unilateral or recreate both sides if it’s bilateral.”

When the muscle is connected to the masseter nerve, patients can smile by clenching their teeth. Alternatively, surgeons can use a graft of the sural nerve connected to the contralateral facial nerve to power the muscle.

“That produces a spontaneous, but weaker smile, while the masseter produces a bigger smile that isn’t spontaneous,” Oyer said. “Now we’re working with both nerves to get the best of both worlds.”

The program is also working to improve nerve grafts and transfers for facial paralysis. These surgeries are an option for patients with short-term paralysis of less than 2 years.

When the masseter nerve is used to power the smile branch, patients can create a smile by clenching their teeth. When the hypoglossal nerve is used, patients trigger desired facial movements with their tongue. While both of these nerves produce stronger results, they aren’t natural movements for patients. By contrast, cross-facial nerve grafts produce more natural, but weaker results and take longer to heal.

The solution? Oyer’s “working with combinations of these techniques to try to achieve spontaneity plus power plus symmetry — small interval improvements.”

Specialized Physical Therapy: Retraining the Face

UVA Health’s program offers a special type of physical therapy called neuromuscular retraining of the face, one of the few in the country to do so. It differs from regular physical therapy by accounting for the unique mechanics involved in moving facial muscles.

“Facial muscles only move skin, while every other muscle in the body moves a joint or bone,” Oyer says. “The training emphasizes achieving symmetry across both sides of the face and producing small, quick movements as opposed to big, strong movements. You’re retraining the brain as to how to work the face, which isn’t necessarily natural.”

This physical therapy is a critical part of recovery.

“It’s like getting a new joint,” Oyer said. “Surgery will only do so much if you don’t have therapy to augment recovery.”

Redefining Success for the Whole Field

To increase patient quality-of-life, UVA Health is working with other facial reanimation centers to expand and standardize measures of success.

“Early on, we focused on questions like, ‘Can we make the mouth move? Yes or no,’” Oyer said. “Then we looked at, ‘Are we making patients feel better?’”

Facial reanimation offers a unique opportunity to take outcomes measures a step further.

“The next step is, ‘How do these smiles look to other people who are seeing them and comparing them to a normal smile?’” Oyer says. “How much better does it look to the patient’s family and friends? Facial expressions are unique in that everyone else shares in the experience, too.”

Spreading the Word

UVA Health’s program serves as a leader in raising awareness and sharing knowledge about facial reanimation.

This outreach requires “spreading the word to non-ENT doctors in neurology, emergency medicine, and primary care. Many providers see a patient with facial paralysis and are under the impression that minimal improvement is all you can do. But that often isn't the case.” Oyer is also part of a group working to grow international and national interest among facial plastic surgeons through educational conferences, webinars, and other opportunities. Additionally, UVA is working to establish a facial plastic surgery fellowship program.

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