Question 1

What are the causes of facial nerve paralysis?

Accepted Answer

Facial nerve paralysis (facial palsy) may have many different causes and can affect individuals of all ages. When no identifiable cause is found despite thorough diagnostic evaluation, the condition is referred to as idiopathic facial palsy, also known as Bell’s palsy, which represents one of the most common forms.
Other identifiable causes include:

Lyme disease
Tick-borne encephalitis (viral meningitis)
Tumors (e.g., acoustic neuroma)
Trauma and accidents (e.g., skull base fractures)

In children, facial nerve paralysis may result from viral or bacterial infections in addition to Bell’s palsy. Tick bites may provide an important diagnostic clue. In middle-aged adults, benign tumors of the vestibular nerve (acoustic neuroma) or the facial nerve itself (facial neuroma) are observed more frequently. In older patients, infections such as herpes simplex or varicella-zoster virus occur more commonly.

Question 2

How can facial nerve paralysis present clinically?

Accepted Answer

Facial nerve paralysis may be partial or complete, affect the entire side of the face or only specific regions, and may change in severity over time depending on the underlying cause.

The condition has significant functional and aesthetic effects on all areas of the face:
The forehead becomes asymmetric with reduced wrinkling
The eyebrow droops, becomes immobile, and may impair the visual field
The upper eyelid may not close completely, leading to drying of the tear film
The lower eyelid may become droopy (ectropium)
The cheek may sag and impair smile and nasal breathing

If left untreated, this can cause inflammation and damage to the cornea, potentially resulting in permanent eye injury. Immediate protective and moisturizing measures are therefore essential. As an initial step, the eye may be temporarily closed with a patch.
The lower eyelid may also become lax, contributing to dry eye symptoms, pain, and excessive tearing. Soft tissues of the midface may descend downward and medially, potentially compromising nasal airflow. Loss of cheek tension can interfere with eating and speaking. Asymmetry and drooping of the corner of the mouth is often particularly distressing, especially during smiling and speech.

Question 3

Eyelid treatment in facial nerve paralysis

Accepted Answer

Protecting the eye is the highest priority. When complete eyelid closure is not possible, the eye is at risk of drying out, leading to inflammation and injury. Initial management includes eye patching, lubrication, and close monitoring by an ophthalmologist.
Incomplete closure of the upper eyelid (lagophthalmos) can be treated using several surgical options. A commonly performed procedure is the implantation of a gold or platinum eyelid weight (solid or chain). The added weight allows the upper eyelid to close through gravity when the patient is upright, while eyelid opening remains unaffected, as it is controlled by a different nerve.
Correction of lower eyelid laxity can also be achieved through various surgical techniques. I regularly perform tarsal strip procedures and the Moe canthopexy, both of which preserve the anatomical continuity of the lower eyelid without transecting its supporting structures.

Question 4

Treatment of the mouth and smile in Facial Nerve Paralysis

Accepted Answer

For many patients, correction of the mouth region is of central importance due to its significant impact on facial expression. In numerous cases, I perform an orthodromic temporalis muscle transfer.
In this procedure, the tendon of a chewing muscle is lengthened using a strip of fascia harvested from the thigh and sutured into the corner of the mouth. The goal is to restore symmetry at rest and enable an active smile. A coordinated movement—smiling on the healthy side combined with gentle clenching of the teeth—can produce a symmetrical, dynamic smile.

Question 5

Treatment of nasal airway obstruction in Facial Nerve Paralysis

Accepted Answer

Nasal breathing impairment caused by facial nerve paralysis is typically treated through transplantation of the patient’s own cartilage into the nasal ala. This cartilage is inserted as a “stairstep graft”, a technique I originally described.
The procedure is performed through an endonasal approach. Further information can be found in the “Rhinoplasty” section.

Question 6

Facial rejuvenation surgery in Facial Nerve Paralysis

Accepted Answer

An asymmetric, bilateral non-delaminating extended deep-plane facelift can significantly improve facial appearance, enhancing symmetry and overall harmony. Among surgical options, facelift procedures often achieve the most pronounced correction of facial asymmetry and visible signs of paralysis. Blepharoplasty and endosopic brow lift procedures are also excellent complimentary options, when indicated.
Additional details are available in the pertinent sections of this website

Question 7

Treatment of synkinesis / Selective neurectomy

Accepted Answer

Patients with facial nerve paralysis may develop synkinesis, characterized by involuntary muscle movements and excessive contractions. I treat these conditions regularly and with long-standing experience using botulinum toxin.
In selected cases, surgical interventions such as selective neurectomy or myectomy may be appropriate and beneficial.

Question 8

Cost and preliminary inquiry

Accepted Answer

If you send us photographs and a short video, I will be happy to provide a non-binding preliminary assessment of treatment options and estimated costs. Please send your material to praxisteam.gassner (at) gmail.com.
The video should be recorded from the front and briefly demonstrate eyebrow elevation, eye closure, smiling, cheek puffing, and lip pursing.
Please also include your name, gender, date of birth, address, and treatment request. I will respond personally. By submitting your data electronically, you consent to electronic communication and acknowledge that data transmission occurs at your own risk in both directions.

Question 9

Before-and-after photos

Accepted Answer

Treatment results for facial nerve paralysis are available in the “Before and After Photos” section.

Question 10

Expertise

Accepted Answer

Over 20 years of focused experience in the treatment of facial nerve paralysis
Close and long-standing collaboration with Professor Kofi Boahene, MD, Johns Hopkins Medical Center
Performance of a large number of corrective procedures for facial nerve paralysis
Long-term patient care including regular botulinum toxin treatments
Current co-author of a comprehensive textbook and atlas on eyelid reconstruction in facial nerve paralysis, together with Professor Boahene and Professor Andrew Harrison

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Treatments / Facial Nerve Paralysis

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Facial Nerve Paralysis

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