Treatments: Facial Weakness or Paralysis
Treatment of weakness or paralysis of the facial nerve depends on its cause, its severity, and how long it has been present, and may include medications, eye protection, therapy, injections, or surgery.
Overview of treatment
Facial nerve weakness or paralysis means that the muscles on one side (or, rarely, both sides) of the face do not move normally. It can affect the ability to close an eye, smile, raise an eyebrow, or keep food and liquid in the mouth. The right treatment depends on the cause, how severe the weakness is, and how long it has been present. Many people recover fully, but some are left with lasting weakness, tightness, or unwanted linked movements (called synkinesis), and treatments exist for each of these situations. More detail about the facial nerve and the causes of facial weakness and paralysis is available on the conditions pages.
Common causes
Bell's palsy – the most common cause. It comes on suddenly, over hours to a couple of days, and no specific cause is found. Most people recover, especially with early treatment.
Ramsay Hunt syndrome – caused by reactivation of the chickenpox/shingles virus (varicella-zoster) near the facial nerve. It often causes a painful ear or mouth rash with blisters, and sometimes hearing changes or dizziness. Weakness tends to be more severe than in Bell's palsy, and recovery is less complete.
Other causes – injury (trauma or surgery), infections such as Lyme disease or middle ear infection, cholesteatoma, tumors (such as parotid salivary gland tumors or acoustic neuroma), stroke, and conditions present from birth. Treatment is aimed at the underlying cause as well as the facial weakness itself.
Medical treatment (medications)
Corticosteroids (such as prednisone or prednisolone) are the mainstay of treatment for Bell's palsy. Taken as a pill, they reduce swelling and inflammation of the nerve and improve the chance of full recovery. They work best when started early, within about 72 hours (3 days) of the first symptoms. Because timing matters and different causes of facial weakness are treated differently, sudden facial weakness is generally evaluated promptly by a physician.
Antiviral medications (such as valacyclovir or acyclovir) target viruses that can inflame the nerve. In Bell's palsy they are not used alone and add only modest benefit; they are usually reserved for severe cases and given together with a corticosteroid. In Ramsay Hunt syndrome, antivirals are an essential part of treatment and are combined with a corticosteroid, ideally started early. Medication for nerve pain may also be added.
Corticosteroids can have side effects (such as raised blood sugar, stomach upset, and mood or sleep changes), so they are prescribed and monitored by a clinician. In children, the benefit of corticosteroids is less clear than in adults.
Protecting the eye
When the eye does not close fully, the surface can dry out and become damaged, which in rare cases threatens vision. Eye care is important with incomplete eyelid closure, regardless of the cause. Common measures include:
Lubricating eye drops (artificial tears) during the day.
Thicker lubricating ointment at night, which lasts longer but can blur vision temporarily.
Taping the eyelid closed or using a moisture chamber or eye shield at night to keep the eye covered and moist. Taping is done only after learning the correct technique.
Glasses or sunglasses to shield the eye from wind and debris.
Evaluation by an eye specialist is commonly helpful when eye pain, redness, irritation, or a change in vision occurs, and for severe or long-lasting incomplete closure.
Physical therapy and facial exercises
Facial retraining (also called neuromuscular retraining) is guided by a therapist experienced in facial palsy. Using slow, controlled, symmetrical movements, often practiced in front of a mirror, it helps rebuild coordination, strengthen weak muscles, and reduce unwanted linked movements (synkinesis) and tightness. Gentle massage may also be used. This approach is especially helpful when recovery is incomplete or when synkinesis develops, and it is often combined with botulinum toxin.
Botulinum toxin (Botox and similar)
Botulinum toxin injections relax overactive muscles. In facial palsy they are used to:
Reduce synkinesis (over-generalized simultaneous movement of facial muscles) and muscle tightness on the affected side.
Balance the face by softening the pull of the stronger, normal side.
Improve eyelid position in selected situations.
The effect appears within days, peaks at about two weeks, and typically lasts several months, so injections are repeated. Results are generally best when combined with facial retraining. Botulinum toxin is also used for cosmetic purposes; more general information about this medication is available on the cosmetic botulinum toxins page.
Surgical options
Surgery is considered mainly when weakness is severe, unlikely to recover, or has not recovered over time. The specific procedure depends on the cause, how much time has passed, and whether the facial muscles are still healthy.
Nerve decompression – an operation to relieve pressure on the swollen nerve. It is used only in selected cases, such as certain severe traumatic injuries or specific severe Bell's palsy situations, and timing is important.
Nerve repair or grafting – when the nerve has been cut or damaged (for example by injury or tumor surgery), the ends can be reconnected directly, or a segment of nerve taken from elsewhere in the body can bridge the gap. This works best when done relatively soon after the injury.
Nerve transfers – a working nerve is connected to the facial nerve or muscles to restore movement. Common donors include the nerve to the chewing (masseter) muscle, which gives strong movement, and the nerve to the tongue (hypoglossal), which restores resting tone and symmetry. A nerve graft taken across the face from the healthy side (cross-face nerve graft) may also be used, sometimes in combination. These are options when the facial muscles are still healthy, generally within roughly two years of the paralysis.
Muscle transfers and free flaps – when the facial muscles themselves are no longer usable (often in long-standing paralysis), a new muscle is brought in to restore a smile. This can use a nearby muscle (such as the temporalis chewing muscle) or a muscle transplanted from the leg (free gracilis flap) reconnected to blood vessels and a nerve using microsurgery. These procedures restore active movement (“reanimation”).
Static procedures – these improve symmetry and function at rest and protect the eye, but do not create movement:
Eyelid weight – a small gold or platinum weight placed in the upper eyelid to help it close by gravity.
Eyelid tightening procedures (such as tarsorrhaphy or canthoplasty) to support the lower lid and improve closure.
Brow lift to raise a drooping eyebrow.
Facial slings – supportive material used to lift a sagging cheek or corner of the mouth.
Ramsay Hunt or herpes zoster oticus.Source: Worme M, Chada R, Lavallee L
Treatment of Bell's palsy and Ramsay Hunt syndrome
Bell's palsy – corticosteroids are started as early as possible (within 72 hours), with eye protection, and antivirals are added to steroids in severe cases. Most improvement occurs over weeks to a few months. Facial therapy, botulinum toxin, and surgery are considered if recovery is incomplete or synkinesis develops.
Ramsay Hunt syndrome – early combined antiviral and corticosteroid treatment, plus eye protection and pain control. Because recovery is often less complete, rehabilitation, botulinum toxin, and reconstructive options may be needed later.
Treatment of injury, tumor-related, and long-standing paralysis
Traumatic or surgical injury – timing is critical. A cut nerve is best repaired or grafted early. Certain severe injuries may be considered for decompression. Incomplete injuries are often watched to see if they recover on their own.
Tumor-related or long-standing paralysis – when the muscles or nerve cannot recover, nerve transfers, muscle transfers or free flaps, and static procedures can restore symmetry, protect the eye, and rebuild a smile.
Key points
Sudden facial weakness has several possible causes, and early medical treatment offers the best chance of recovery in many of them.
Protecting the eye is essential whenever the eyelid does not close fully.
Recovery can take weeks to many months; a range of therapies and surgeries can help when recovery is incomplete or delayed.
Care is individualized and often involves a team (primary care, neurology, ear-nose-throat/facial plastic surgery, eye care, and specialized therapy).