Physiotherapy and Surgery for Facial Nerve Paralysis

By: Rebecca Tomasi, PT
March 31, 2021
Editors: Ryan Davey, PhD and Lindsay Davey, MScPT, MSc, CDT

Imagine losing your ability to convey tone and emotion through facial expressions. The loss of facial function due to facial nerve paralysis can significantly affect confidence and emotional wellbeing. Facial nerve paralysis is a result of damage or injury to the seventh cranial nerve, a.k.a. the facial nerve. The facial nerve controls facial expression, salivary function, taste in parts of the tongue, and has a small role in ear function (1).

Treatment Options

Elias Peixoto, Registered Physiotherapist at our Yonge & Summerhill clinic, regularly sees patients with facial nerve paralysis and will be happy to explore the physiotherapy treatment approaches used in the management/rehab of Bell’s Palsy, tailoring his approach based on your individual case and presentation.

Understanding the cause (Fig. 1) and extent (complete or incomplete) of facial nerve paralysis is important in guiding treatment and in setting patient expectations for recovery (‘prognosis’) (1). Treatment options may include both physical rehabilitation (including manual therapy, acupuncture, and instruction on specific facial exercises), and surgical interventions.

Causes of facial nerve paralysis

Fig 1. The four overarching categories of potential causes for facial paralysis organized by incidence (1).

Physiotherapy for Facial Nerve Paralysis

Physiotherapy can be an essential part of your journey to recovery after facial nerve paralysis and should be offered regardless of how transient or chronic the paralysis is (2). When to see a physiotherapist, and what that physiotherapy care might look like will depend on the cause and prognosis of the nerve paralysis, as well as any follow-on issues (‘sequelae’) that the paralysis may have caused (3).

The potential consequences of facial nerve paralysis include little-known neuromuscular conditions such as synkinesis, asymmetry, hyperkinesis, muscle atrophy, and contracture.  The most common of these outcomes is synkinesis, a condition where the deliberate contraction of muscles in one area of the face causes an involuntary contraction in another. For example, oral-ocular synkinesis is the involuntary movement of the mouth during voluntary eye movement (such as blinking or eyebrow raising). Synkinesis is thought to arise from poor nerve regeneration during the healing process of the facial nerve. Research suggests that patients with incomplete recovery after facial nerve paralysis can benefit from a physical rehabilitation program including neuromuscular re-education, exercise therapy, and biofeedback (4,5).

Physiotherapy treatment may include:

  • Soft tissue massage and stretching to address adaptive shortening/tension of impacted muscles.
  • Acupuncture to help stimulate the facial nerve’s healing and motor function recovery, and/or decrease the tone in muscles that may show overuse/tension.
  • Development of an individualized exercise program to address facial asymmetries. This may involve biofeedback and/or mirror therapy to work on muscle strengthening and importantly, muscle patterning, control, and coordination.
  • Education regarding facial muscles and their function, expected progression, and timeline of recovery.

Surgical Options for Facial Nerve Paralysis

Along with conservative management in the form of physical rehabilitation, there are many potential surgical interventions that can help. Two common surgeries include neural repair where a damaged nerve is sutured back together, and neural decompression where structures compressing the nerve are removed (6).

Patients where neural repair or decompression are not possible or unsuccessful may be referred to a plastic surgeon like Dr. Baltzer at the Toronto Western Hospital to undergo a more involved surgical procedure known as “facial reanimation”. Dr. Baltzer is one of a handful of surgeons in Canada who perform facial reanimation surgery in adults (7).

Unlike neural repair or decompression which attempt to recover the function of the existing damaged nerve, the goal of facial reanimation surgery is to provide an entirely new neural input to the facial muscles that have been left dysfunctional by nerve damage. This can be done in one of three ways: nerve graft, nerve transfer, or a combination of both (Fig. 2). A nerve graft involves transplanting a piece of a healthy nerve from another part of the body into the affected area where it will then have to regenerate. A nerve transfer involves borrowing a nerve branch from a nearby area and attaching it to the affected muscle. Picture replacing a wire (nerve graft) versus plugging a wire into a new plug (nerve transfer) (7). Additionally, in some cases nerve grafts and/or transfers occur alongside muscle transplants. This would be recommended in cases where the facial muscle has been significantly damaged or atrophied as a result of the initial nerve damage. In fact, facial reanimation surgery ideally takes place within one year of facial paralysis to avoid more significant muscle atrophy that can occur (6).

Facial nerve graft surgery

Fig 2. Combination of nerve graft and transfer using a nerve from the leg to supply input to the paralyzed side of the face. Modified from Ref 6.

Post-surgical Physiotherapy

Physical rehabilitation plays an important role in post-surgical recovery as well. Since 50% of those treated surgically will develop mild or moderate synkinesia (8), it is not surprising that post-surgical physiotherapy treatment can look very similar to non-surgical physiotherapy care. In addition to the physiotherapy treatments listed above, post-surgical physiotherapy for facial nerve paralysis may also employ manual lymphatic drainage techniques to help manage surgery-related swelling (9).

The timeline for initiating post-surgical physiotherapy will largely depend on need as assessed by the surgeon. With that said, there is evidence to support the efficacy of post-surgical physiotherapy throughout the recovery period, as early as 5 weeks post-surgery (9), and for chronic cases as late as 13 years  following nerve paralysis (10).  Regardless of the timeframe, the treating physiotherapist will establish a treatment plan based on four categories that pertain to typical signs and symptoms: initiation, facilitation, movement control, and relaxation (see Table 1) (3).

Table 1. Symptom-based categories which guide physiotherapy treatment approach. (Modified from Ref 3).

CategoryCorresponding Signs and Symptoms


Drooped facial posture at rest, inability to initiate movement or very minimal movement, marked functional problems with speaking/eating/expression
FacilitationMinimal droop at rest, mild-moderate facial muscle weakness
Movement controlNarrowed eye, deepened cheek crease, mild to moderate facial muscle weakness, synkinesis
RelaxationResting facial tension, facial twitches/spasms, marked psychosocial difficulties

Facial paralysis is a challenging and complex condition, but significant recovery can be possible. Optimal results are typically realized through a multidisciplinary approach and collaborative treatment plan.


  1. Mavrikakis I., Facial Nerve Palsy: Anatomy, Etiology, Evaluation, and Management. Orbit. 2008; 27, 466-474.
  2. Karp E., Waselchuk E., et al. Facial Rehabilitation as Noninvasive treatment for Chronic Facil Nerve Paralysis. Otology & Neurology. 2018; 40, 241-245.
  3. Brach J., VanSwearingen J., Physical Therapy for Facial Paralysis: A Tailored Treatment Approach. Physical Therapy. 1999; 79(4), 397-404
  4. Pourmomeny A., Asadi S., Managment of Synkinesis and Asymmetry in Facial Nerve Palsy: A Review Article. Iranian Journal of Otorhinolaryngology. 2014; 26(4) 251-256.
  5. Liapids J., et al. Too much or too little? A systematic review of post paretic synkinesis treatment. Journal of plastic, Reconstructive & Aesthetic Surgery 2020; 73, 443-452
  6. Mehta R., Surgical Treatment of Facial Paralysis. Clin Exp Otorhinolaryngol. 2009 Mar; 2(1): 1–5.
  7. Not Just reason, but ability to smile again:
  8. Placheta E., et al., Facial Synkinesia before and after Surgical Reanimation of the Paralyzed Face. Plastic and Reconstructive Surgery. 2014; 133(6).
  9. Wilsion C., Ronan S., Rehabilitation Post facial Reanimation Surgery After Removal of Acoustic Meuroma: A Case Study. JNPT. 2010; 34: 41-49.
  10. Cronin G., Leif Steenerson R., The effectiveness of neuromuscular facial retraining combined with electromyography in facial paralysis rehabilitation. Otolayngology-Head and Neck Surgery. 2003; 128(4), 534-538


  1. ST ST says:

    Hi Rebecca,

    Great post! There haven’t been a lot of exposure or many articles about Bell’s Palsy and the potential surgical options.

    I have unfortunately, been hit with Bell’s Palsy twice. The first time around, I was fully recovered. The second time around, I partially recovered…I would be interested in understanding how to get to the surgical route.


    • Hello Sung,

      Thank you for your comments – so sorry to hear that you have experienced this challenging condition twice. Was it on the same side of the face, may I ask? The surgical route is very exciting indeed, for appropriate candidates. I can recommend you seek out a consultation with Dr. Heather Baltzer, at Toronto Western Hospital. Your family physician could send a referral to her and she could discuss whether or not she feels a surgical route would be beneficial for you. Wishing you all the best Sung, in your on-going recovery.

  2. Sung Sung says:

    Hi Lindsay,

    Thank you for responding to my comment!

    The first time around, it was on the right side of my face and it fully recovered.

    The second time around, it was on the left side of my face and most of it has recovered. I have feelings so my sensory nerves are working, but I am unable to fully move my lip and forehead.

    I will have a chat with my family doctor and see whether I can get a referral.

    Thanks again,

  3. Roma Kay Roma Kay says:

    I am so thrilled to read these options. I have already requested for a consult with Dr. Heather. Got hit with Bells nearly 6 years ago and only recovered partially. This has been so debilitating, cannot even express how harsh the impact has been with work and personal life.

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