Congenital facial paralysis

Sometimes people are born with weakness on one or both sides of the face. Syndromes that commonly are associated with facial weakness include Goldenhar’s Syndrome/hemifacial microsomia, CHARGE Association, and VACTREL syndrome. The weakness might involve all of the divisions of the face, or only the upper, central, or lower part of the face. Congenital bilateral facial paralysis is usually referred to as Mobius syndrome.  Facial weakness at birth can be related to a genetic mutation, or as part of a syndrome, or it can be related to in-utero or birth trauma. The only way to distinguish between a genetic problem or syndrome, and trauma, is to observe for signs of recovery.  Usually birth trauma and in-utero positioning problems will result in some degree of recovery, even though recovery might not be perfect.  In the modern age, birth trauma and in-utero insults are much less likely than simple genetic mutations or syndromes, and they are not highly suspected when patients are born with facial weakness. Every condition of congenital facial paralysis is managed a little bit differently. Quite often, patients do beautifully from a developmental standpoint, and do not require any intervention at all until they become school-age and they get interested in trying to achieve more facial balance or have a more meaningful smile.  Interestingly, children who are not able to close their eye well even from birth, are able to adapt much more easily than adults who lose facial function.  There are many options for children with congenital facial paralysis, ranging from simple injections to weaken the overactive healthy side of the face, all the way through surgery to restore dynamic smile. Physical therapy also plays an important role in optimizing function for children, and by around the age of four, children are able to be fully cooperative with this type of exercise. Most centers would agree that children below the age of five or six are not as good candidates as patients over that age, for formal facial reanimation, because as children grow their vessels get larger and the likelihood of successful muscle transfers becomes higher.  For that reason, the earliest we typically perform facial reanimation surgeries is age 5-6. 

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Congenital Unilateral Lower Lip Palsy (CULLP) is a term used to describe when patients have an asymmetric smile, but the corners of their mouth go up nicely and the remainder of their face works normally, but during smiling they are unable to show the bottom teeth on a single side. When kids are born with this, their smile looks quite asymmetric. Luckily, it is relatively straightforward to treat, with a simple weakening technique to the opposite side, which restores balance, and dramatically improves the appearance of the smile. Usually when kids are old enough, we perform a tiny injection in the office to be certain that they like the effect, and then we can go ahead and actually remove the over-active muscle in the opposite lower lip, to restore balance. There are also emerging techniques to restore movement to the opposite lower lip, and we are very likely to see some of these techniques perfected in the next decade.

Treatments

  • Pharmacologic weakening of the healthy side (Botox)

  • Permanent office based weakening of the healthy side (DLI Excision)

  • Dynamic lower lip reanimation with Cross Face Nerve Graft and muscle transfer

Bilateral facial paralysis can be caused by a number of conditions. The most common of these are the congenital condition, Moebius syndrome, or Lyme disease.  Another frequent cause of bilateral facial paralysis is Guillain-Barré syndrome, which is an ascending polyneuropathy, with an auto-immune component.   There is a variant of GBS that only involves the face, which is called Miller Fisher syndrome, and is treated the same way as GBS. Often GBS and Miller Fisher syndrome are triggered by some kind of viral infection. 

            Other causes of bilateral facial paralysis include bilateral skull fractures involving both temporal bones, certain kinds of brain infections like meningitis, certain cancers like lymphoma that get into the spinal fluid, causing bilateral weakness.  Sarcoidosis, a granulomatous disease, can also cause bilateral facial paralysis, as can certain kinds of leukemia, infectious mononucleosis (mono), and acute HIV infection.

            Treatment for bilateral facial paralysis is completely dependent upon what has caused it. Certain conditions, like temporal bone fractures, might require surgery, where others require medical therapy specifically to control the disease which is causing the nerve problem. Extremely personalized diagnosis and management is essential when patients develop bilateral facial weakness.