You hardly think about how wonderful it is to smile—until you can’t.
That’s the devastating realization Gabrielle Biskaduros had when she suddenly couldn’t move the right side of her face.
“I noticed during my haircut that my smile looked off and felt a little numb, and the next day I lost all facial movement on one side,” the 31-year-old says. “I went to urgent care and was told I had a textbook case of Bell’s palsy.”
Although Biskaduros was grateful the paralysis was not caused by a stroke or a tumor, she still had a long road ahead to regain her facial function. That road led her to Matthew Q. Miller, MD, a UNC Health facial plastic surgeon who also has personal experience with facial paralysis (asymmetry of the face).
We asked Dr. Miller to explain what Bell’s palsy is, how it is treated and how his team gave Biskaduros the ability to smile again.
What is Bell’s palsy, and who is at risk?
To understand Bell’s palsy, it’s important to know that the facial nerve controls facial expressions. The nerve starts in the brainstem, travels through the temporal bone (the part of the skull where the ear sits) and then divides into tiny branches (many less than 1 millimeter wide) across the face. The branches connect with facial muscles to create facial expressions.
Acute Bell’s palsy occurs when the herpes virus suddenly reactivates in the facial nerve, making the nerve swell. The temporal bone compresses the swollen facial nerve and causes it to stop working.
“Most people have the herpes virus living dormant in their bodies,” Dr. Miller says. “While herpes virus reactivation most commonly causes cold sores, 1 in 60 people will develop Bell’s palsy during their lifetime, and many of these patients have never had a cold sore before. It can happen to anyone. Many patients are healthy and have never had a medical condition before.”
Stress can make it more difficult for your body to fight off the herpes virus as it reactivates, likely contributing to both the incidence and severity of Bell’s palsy, Dr. Miller says.
“A virus started to attack my facial nerve at a time in my life where I was really busy with work and dealing with other outside stressors,” Biskaduros says. “Since I wasn’t taking care of my body well, I had a hard time fighting it off.”
Pregnancy also can increase the risk of Bell’s palsy, especially during the third trimester or right after giving birth.
The effects of acute Bell’s palsy can include being unable to smile, drooling, and having difficulty closing the eye, eating and drinking, and breathing through the nose. Patients often look like they have had a stroke, even though they have not, Dr. Miller says.
Many people mistakenly refer to all facial paralysis as Bell’s palsy; however, it is just the most common cause of facial paralysis.
What are the symptoms of acute Bell’s palsy?
The facial nerve is complex, and damage to it can cause a variety of symptoms. The most common symptom of Bell’s palsy is sudden weakness on one side of the face.
“A common story I hear is the patient was smiling and laughing the day before, but they wake up the next morning, brush their teeth, and water spills out of their mouth because their facial muscles have stopped working,” Dr. Miller says.
Other symptoms can include:
- Drooping of the mouth
- Inability to close an eye
- Excessive tearing in one eye
- Altered taste
- Intolerance to loud noise
Acute Bell’s palsy develops quickly. Usually, someone with Bell’s palsy will experience loss of facial movement within three days, and often within 24 hours, Dr. Miller says. Facial weakness that progresses over weeks to months is not Bell’s palsy and should be evaluated to determine the cause.
If you notice any symptoms, Dr. Miller says to seek medical attention right away so doctors can confirm the cause of your facial paralysis and start treatment immediately.
How is acute Bell’s palsy treated?
If you are diagnosed with acute Bell’s palsy, evidence shows that being treated with a course of steroids maximizes your chances for a complete recovery. Taking an antiviral drug along with steroids can also improve recovery, Dr. Miller says.
These medications should be started right away — which is why you should not hesitate to seek medical attention at the first sign of facial weakness. If you can’t close your eye as you’re recovering, it’s important that you take steps to protect it. Use eye drops and ointment to keep it moist. If it’s windy, wear glasses or sunglasses. At night, you can tape your eye closed to protect it while sleeping.
Even if you are prescribed treatment right away, regaining facial function is a gradual process, and recovery times vary. Some people regain their facial function in days; for others, it can take four to six months.
“As you recover from acute Bell’s palsy, facial nerve branches have to regenerate and reconnect with the facial muscles,” Dr. Miller says.
About 70 percent of people with acute Bell’s palsy will fully recover, Dr. Miller says. The other 30 percent will develop chronic Bell’s palsy.
How is chronic Bell’s palsy treated?
Chronic (long-term) Bell’s palsy occurs when some of the branches of the facial nerve don’t reconnect properly with the facial muscles, which is called aberrant facial nerve regeneration. Symptoms of chronic Bell’s palsy include:
- Smile asymmetry
- Facial asymmetry
- Facial synkinesis, or involuntary facial movements such as the eye closing when a person smiles
- Narrowing of the eye
- Facial tightness
- Neck tightness
If this happens to you, there are several treatment options available. If one doesn’t produce the desired result, you can try another. Even if you have had Bell’s palsy for decades, there are new treatments that can help, Dr. Miller says.
Treatment options for chronic Bell’s palsy include:
- Targeted facial physical therapy (neuromuscular retraining)
Targeted therapy is the best place to start with treatment. Massages, stretches and other exercises can help balance your face, control involuntary movements and relax tight muscles. Patients should work with a therapist who has specialized training in facial nerve disorders, such as Heather Davis Cuevas, who works with Dr. Miller’s patients.
- Botox injections
Botulinum toxin, aka Botox, is an injectable neurotoxin that temporarily weakens muscles. It helps relax muscles that are too tight and can help prevent involuntary facial movements.
- Surgeries to improve a smile
When it comes to improving a patient’s smile, though, many people with chronic Bell’s palsy will also require surgery to obtain the best results. Often, people who have smile asymmetry due to chronic Bell’s palsy are told there is nothing they can do to get their smiles back. Dr. Miller says that is far from the truth.
“In the last five to 10 years, two new procedures have been developed to help patients smile again,” Dr. Miller says. “And this is critically important because research shows if you don’t smile, you are more likely to become depressed, have anxiety and withdraw from social activities.”
Dr. Miller is so passionate about improving patients’ smiles and facial paralysis because he knows firsthand how important it is to give people back their self-expression.
“In college, I was training for a triathlon and collided with a car while on a bicycle training ride, resulting in traumatic brain injury, facial fractures and facial paralysis,” Dr. Miller says. “As a result, I couldn’t move my face for about seven months. I vividly remember how devastating it was to not be able to express myself, to not be able to smile and show happiness. And I remember how life-changing it was as my smile recovered.”
The first of two new procedures to help improve smile symmetry is the DAO excision. DAO stands for depressor anguli oris, one of the muscles that helps a person frown and that can become too strong after Bell’s palsy and other causes of facial paralysis, leading to smile asymmetry. During DAO excision, which can be performed in a clinic, a surgeon takes out the DAO muscle to improve the smile.
“When it comes to improving smile symmetry for patients with chronic Bell’s palsy, we typically start with the DAO excision, as it can give patients the improvement they desire in a minimally invasive and minimal-risk fashion,” Dr. Miller says. “Patients can often return to work the next day.”
Sometimes patients with chronic Bell’s palsy have other muscles creating smile asymmetry. These patients are often candidates for the selective denervation procedure, which is performed in the operating room under general anesthesia. A surgeon makes an incision by the ear, uses precise nerve stimulation to identify which nerve branches are contributing to facial asymmetry and then removes them, essentially rewiring the face.
“The selective denervation procedure can give life-changing results, including an improved smile, improved resting symmetry and less facial tightness,” Dr. Miller says.
Giving Back the Ability to Smile
Gabrielle Biskaduros came across Dr. Miller while doing research on how to bring back her smile. Although she saw slight progress over six months, it didn’t fully come back. She had gotten opinions from several doctors on what she should do, but she couldn’t decide until she met Dr. Miller and his medical assistant Carter Ballard, who also receives treatment for facial paralysis due to Bell’s palsy.
“Dr. Miller and Carter have walked this road, so the ability to connect with them in that unique way gave me the comfort I needed to move forward with treatment,” Biskaduros says. “They’ve had the same struggles as me and have been on the same emotional roller coaster, so I knew they would be the best to help me.”
Biskaduros started with a few rounds of Botox injections and then underwent both DAO excision and selective denervation.
“I can definitely tell improvement after surgery,” Biskaduros says. “I know my smile won’t be perfect again, but this is the closest I’ve ever felt to my old self and is a huge step forward for me. A lot of living with chronic Bell’s palsy is learning to accept it and find ways to build more confidence in myself, knowing that I don’t look the same as I did before.”
Biskaduros is continuing her Botox treatments and performs physical therapy.
While patients often see an improved smile and facial symmetry within a few weeks after selective denervation surgery, symmetry continues to improve for up to two years. If patients ultimately do not get the results they desire, doctors can perform revision surgery and other procedures, Dr. Miller says.
“While surgeons are never able to fully reverse facial nerve damage induced by chronic Bell’s palsy and other causes of facial paralysis, there are more treatment options today than there were 10 years ago. My team is continually working to move the needle forward with each patient we see. I tell patients we will not stop working with them until we get to a point where they are happy,” Dr. Miller says.
Looking for a facial plastic surgeon? Find one at the UNC Facial Nerve Center.