Jan 25, 2023

Interviewer: As patients and loved ones of patients who have suffered from Bell's palsy know, the loss of one's ability to move one's face can be really serious and impact their lives. And if it's lasted for longer than six months or so, a surgical option may be available to give back a loved one's smile and ability to move their face.

We're joined by Dr. Sarah Akkina. She is the Assistant Professor of Facial Plastic and Reconstructive Surgery at the Department of Otolaryngology and Director of the Facial Nerve Center at University of Utah Health.

Now, Dr. Akkina, briefly, what is Bell's palsy and why is facial paralysis so potentially life impacting?

What is Bell's Palsy?

Dr. Akkina: Bell's palsy is a rapid, or less than 72 hours, one-sided facial nerve weakness of unknown cause, meaning we don't have an alternative reason for a patient to have it.

It's really important to know that recovery from Bell's palsy should start two to three weeks after. So that as an entire category really classifies Bell's palsy.

There are other conditions that can cause facial weakness, and that includes stroke, brain tumors, salivary gland tumors, cancers, and infectious diseases, including things like Lyme disease or a tick-borne disease.

Overall, we suspect that Bell's palsy is related to swelling around the facial nerve, probably related to an unnamed or unknown virus. The nerve that travels from the brain to the face to control face movements is in a very small bony canal at the base of the skull. So swelling in that area can lead to compression and that can cause the dysfunction that we see.

The facial nerve controls muscles in the face, but it also controls tear glands, saliva glands, a muscle in the ear, and taste to the front of the tongue, as well as sensation to the eardrum and parts of the ear canal. So outside of the obvious facial weakness, patients with Bell's palsy can also have dryness in their eyes and mouth, a change in taste, sensitivity to loud sounds, and a change in the sensation of the ear.

So while patients recover, they can have debilitating functional losses in the short term, and that includes the inability to close their eye, trouble keeping food and liquid in their mouth, nasal obstruction, and overall difficulty expressing emotions. So they can't smile on that side of the face, which obviously impacts everyone's day-to-day lives.

Treatment Options for Bell's Palsy

Interviewer: Wow. And so for patients who are maybe suffering from these different symptoms, whether it be facial paralysis, or inability to tear, or asymmetry, etc., what options are available for patients who are still experiencing those types of symptoms longer than is typically expected for healing, say, six months or so?

Dr. Akkina: For overall treatment of patients who have Bell's palsy with incomplete recovery, meaning they still have some muscle weakness, some asymmetry of their facial movements, or some major functional issues like being able to keep food or liquid in the mouth or nasal obstruction, we have a series of treatments that we can provide for those patients.

We provide treatments that are focused on both moving, or dynamic, and non-moving, or static, facial reanimation. Static procedures are focused on improving the overall symmetry of the face at rest, and that includes procedures focused on the brow, the eyes, the nose, the mouth, and the cheek.

Dynamic procedures can bring back facial movement itself, and that includes surgeries that connect working nerves to non-working nerves, as well as surgeries that transplant nerves or muscles from nearby or separate areas of the body.

For patients that have developed abnormal facial movement after facial paralysis called synkinesis, we offer procedures to reduce that abnormal movement, including chemodenervation, or using botulinum toxin injections, or Botox/Dysport/Xeomin, as well as selective neurectomy. And this is cutting nerves that lead to the abnormal movements. We can also cut selective muscles that are moving abnormally.

So there's a variety of ways that we can really delve into exactly what is abnormal for a patient and help them in these matters.

Interviewer: Wow. So you just described quite a few procedures. These are all under the umbrella of facial reanimation?

Dr. Akkina: Correct. Yeah.

What is Facial Reanimation for Bell's Palsy?

Interviewer: Wow. So what kinds of patients are, say, eligible for these types of procedures? Is there anyone that for one reason or another would not be eligible for something like this.

Dr. Akkina: So by group, I'll say, for things like nerve transfers, it's important to know . . . For Bell's palsy, we don't assume that there are other nerves that are affected. But for patients who may have the facial paralysis because of other skull-based tumors or other pathologies that may then affect other nerves, we have to make sure that the nerve we connect to the non-working nerve is going to work, if that makes sense.

Interviewer: Sure. Okay.

Dr. Akkina: For muscle therapies, a lot of patients will qualify for different work such as cutting muscles that are abnormally moving. But for moving muscles, so sometimes if a patient has permanent, abnormal movement of their smile, we can transplant a muscle from their leg into their face to basically recreate their smile muscle movement.

That, of course, does require that that patient's a good candidate to be able to undergo a long surgery where we transplant that muscle. They have good arteries and veins in their face that we can connect it to and are otherwise healthy from other standpoints too.

So, as you can tell, it is pretty individual-based, and that's why it's so important to be able to see a specialist who can talk you through all these different options.

Interviewer: And the specialist that they're looking for is a facial nerve specialist in surgery?

Dr. Akkina: Correct.

Interviewer: I guess this might be a strange question, but considering how tailored and kind of unique it is per patient, what kind of success rates do you see with your patients?

Dr. Akkina: We can get great success rates, especially with nerve transfers. One critical part is that timing is super important. So we talked about for things like Bell's palsy, if you have abnormal movement after three months, you should get immediately referred to a facial nerve specialist. Because overall, for some of these nerve transfers to work, we only have 12 to 18 months before that facial nerve itself may not work very well even if we connect it to a better nerve that can give it more input.

So overall, for the nerve therapies, we really need to see patients, again, ideally within 12 months so we can start planning for whether they may be a candidate for the nerve surgeries.

That muscle transfer surgery can be done essentially at any time. That one we like to wait a little bit longer to know that they won't recover from the other standpoints and that they may not recover from things like the nerve transfers. But that is a really great option for patients who don't qualify for the nerve transfers themselves.

Interviewer: And for the static procedures, it's mostly for cosmetic, mostly for that kind of situation, or . . .?

Dr. Akkina: Both cosmetic and function. So the static procedures, they can really help with, for instance, for the eye work, again, closing the eye. So being able to maybe not necessarily use as many eye drops or have to tape the eye at night, things like that, our eye procedures can give that function back.

Another really great thing is . . . Outside of the symmetry, the nose can be droopy, so a lot of patients have nasal obstruction. And some of our static procedures, one called a static sling where I take fascia from the leg and reattach it to parts of the face, bring back basically support of the nasal valve and support of the mouth, so it's not drooping so much.

So it helps both the appearance of the face and the function in terms of that droopiness, which is why a lot of patients have difficulties with chewing food or keeping food and liquids in their mouth. So the static procedures can help both of those aspects.

Interviewer: We're just not necessarily replacing muscles or reconnecting nerves.

Dr. Akkina: Exactly.

Interviewer: We're doing structural things. Okay. Interesting. So what are some of the potential complications that come with these types of surgeries?

Dr. Akkina: Yeah, one of the main complications is sometimes for the nerve transfers, the nerves unfortunately don't connect as we like or don't eventually function as we like. But we do like to work with our physical therapists very intimately for those procedures as well, to teach patients how to use those new nerve connections.

One example is that we can connect a nerve that controls one of the muscles of mastication, or one of the muscles that's responsible for us closing the jaw, back to the facial nerve. But that does mean that a patient essentially has to clench their jaw to activate their smile. So there are different physical therapy things to learn about that, to teach a patient how to use their new nerves correctly.

Some of the complications that always exist for surgeries are things like bleeding, infection of the site, sometimes failure of the static sling procedures where we don't get as much of a lift of the face as we want, as well as ultimately relaxing of the face again.

Gravity wins always at the end, so even if we do these procedures when a patient is, say, in their 30s or 40s, over time the face will continue to droop and may need additional procedures in the future.

The Cost of Facial Reanimation for Bell's Palsy

Interviewer: Well, this is kind of really exciting to hear about all the potential ways that we can work on this, but what does this kind of procedure cost and is this something that is covered by insurance?

Dr. Akkina: Great question. So this procedure is typically covered by insurance. That's the number one thing, especially for things related to overall facial paralysis. Typically, insurance will cover any procedure related to that facial nerve motor dysfunction.

There are insurances that won't cover some smaller procedures. Sometimes things like the brow lift on that side of the face, because it is very focused on the symmetry and appearance of the face, has difficulty getting covered by insurance. But for the most part, a lot of these advanced procedures we've discussed will be covered.

How to Choose a Facial Nerve Specialist

Interviewer: So we've got a patient, and they're dealing with this kind of long-term facial paralysis. What should they be looking for in a doctor? If they want to explore some of these potential facial reanimation options, what kind of doctor are they looking for, and are there any particular trainings or certifications or something that they should be searching for?

Dr. Akkina: Absolutely. The first thing I'll note is that taking care of facial nerve disorders is a team sport. So we have, in our facial nerve center, multiple specialists from different aspects that all come together to collaborate and care for our facial nerve patients.

So our team includes experts in facial plastic surgery, neurotology, otolaryngology, head and neck surgery, oncology, ophthalmology, facial nerve rehabilitation. So you can get a sense that there are so many different aspects that we can come together to treat for patients.

And each specialist focuses on their area, but certainly in a facial nerve center setting, we can all basically collaborate on our individual aspects.

Initially, I think it is important to see a specialist who's at least aware of many of the procedures and treatments that we can offer. So, typically, facial plastic surgeons or even some neurosurgeons are focusing their practice on these areas.

This is an exciting field where we do have development of new techniques and new practices that are coming out each year. So being at an academic center can also really help because specialists in these centers are usually up to date on the latest knowledge, if not performing some of these trials and experiments ourselves. So going to folks who are most up to date on what's going on, I think, is also important.

For facial plastics, there are board-certified surgeons who have additional training and are, again, certified on a particular level with that training. So I would recommend always seeking a board-certified surgeon, especially moving forward with the surgical treatments.

Interviewer: So I guess look for a board-certified surgeon maybe at an academic center, or just look for that doctor that will be able to help you get the type of treatment that you need.

Now, as a patient who might be first starting out onto this, first looking into potential options, or a loved one of a patient, what is the message that you have for them in kind of starting this journey towards facial reanimation?

Dr. Akkina: Yeah, my main message is that, one, you're not alone, and two, there are ways that we can help. Even if that's mainly connecting a patient with a therapist to work on facial retraining or discussing some of these more advanced, both surgical and injection options, there is likely a way that we can help. And we want to work with you and evaluate all these aspects that you're going through.

Places like a facial nerve center will have multiple specialists who are all geared towards helping this very special patient population. So we want to help you. Please come find us.

For Patients