The facial muscles are the only muscles of the human body that have direct connections to the overlying integument. Using these connections, the facial muscles are able to perform a variety of functions of both physiologic and sociologic importance. Physiologically, the facial muscles provide sphincters for the eye and mouth that are crucial for eye protection, eating, drinking, and speaking. The facial muscles also function to modify the diameter of the nostrils, affecting breathing through the nose. Although these functional considerations are important, they are perhaps overshadowed by the role played by the human face in social interactions. The human face is unique across the animal kingdom because of its ability to express a wide range of emotions and intents. In lower animals, facial expressions are used primarily to express anger or aggression. The human face is capable of clearly signaling to other humans the four major emotions—fear, anger, happiness, and sadness—as well as more subtle nuances—sympathy, disgust, amusement, disbelief, and surprise. Facial expressions have clearly evolved to aid in the social interaction of humans. Paralysis of the face significantly compromises an individual’s ability to function effectively in society. Patients with a facial paralysis have a distinctly abnormal appearance, which makes others uncomfortable. Human societies have always tended to marginilize those who are considered “different.” In addition, there may be the unspoken fear that whatever is affecting the face is contagious and, as a result, routine physical contact, such as handshaking, is avoided. The appearance of a paralyzed face is often interpreted as one of anger or disapproval, which can be intimidating to others, especially children. Patients with a facial paralysis typically avoid having photos taken and eventually drop out of a family’s photographic record. Also, patients with a facial paralysis begin to avoid social functions and family gatherings. Social isolation may be compounded at the workplace, where job advancement, and even hiring, may be adversely affected.

Goals of Rehabilitating the Paralyzed Face

Facial paralysis has two major consequences: loss of volitional facial muscle motion and loss of baseline muscle tone. The loss of muscle motion leads to the functional debilities noted with facial paralysis, such as the inability to blink, to purse the lips, and to flare the nostrils. The loss of baseline facial muscle tone is responsible for many of the changes in facial appearance associated with facial paralysis, such as drooping of the ipsilateral face and deviation of the nose to the contralateral side. The ultimate goal of rehabilitating the paralyzed face would be to restore normal facial tone and function. However, it must be recognized by both physician and patient that no single technique (or combination of techniques) will restore normal facial tone and motion. It is the responsibility of the treating physician to be knowledgeable with regard to the various treatment options and to present these options to the patient in such a fashion that an informed decision may be made by the patient. For example, an 80-year-old individual with facial paralysis and multiple medical problems may be very satisfied with simple restoration of eyelid closure alone, whereas a 25-year-old individual may strive to have every nuance of facial motion restored. It remains for the surgeon to weigh the therapeutic options available against what is appropriate for each patient.

Management of the Paralyzed Eye

Most of the changes associated with facial paralysis are not life-, or even health-, threatening and are primarily quality-of-life issues. However, the ability to blink and lubricate the eye is crucial to providing a stable and comfortable eye. Toward this end, upper lid loading with gold weights and lower lid tightening have supplanted older techniques, such as slings and springs. Therefore, management of the paralytic eye is not discussed further in this section.

Methods of Rehabilitating the Paralyzed Face

Hypoglossal to Facial Nerve Transfer