Facial paralysis: and when the face doesn’t return to being the same?

Synkinesias, asymmetries and facial tension may persist after a facial paralysis. But recovery should not necessarily end when movement returns. Specialized physiotherapy can help regain control, coordination and the naturalness of facial expression, even years later.

When facial paralysis occurs, the initial concern is almost always the same: will I be able to move my face again? Will I be able to close my eye? Will I be able to smile again? Will I be able to regain the expression I had before?

For many people, the first months are marked by a progressive evolution. Gradually, some movements return, asymmetry decreases, and the face begins to regain some of its function. But recovery does not always happen as we would like.

Sometimes the movement returns, but not in the same way. The smile may remain asymmetrical, the eye may involuntarily close when we try to smile, the mouth may contract when blinking, or there may be a constant feeling of tension in a part of the face.

And it is precisely at this stage that many people begin to question themselves: is there really nothing more to be done?

The answer is no. Even when residual effects persist, even if several months or years have passed since the facial paralysis, it is still possible to work on the function and improve the quality of movement.

When the movement returns, but the face is no longer the same

The recovery from facial paralysis depends on several factors, namely the cause, the extent of the facial nerve injury, and the ability of nerve regeneration.

During this process, the nerve fibers can regenerate in an disorganized manner, establishing connections with muscles that are not those that should originally control them.

As a consequence, involuntary and poorly selective movement patterns may arise.

It is in this context that some of the most common sequelae of facial paralysis appear:

• Synaesthesia involuntary movements that accompany a voluntary movement.
• Contractions: persistent increase in tension and functional shortening of certain facial muscles.
• Asymmetries: differences between the two sides of the face, both at rest and during movement.
• Spasms and involuntary movements: constrictions that can arise spontaneously or be associated with certain expressions.
• Functional changes: difficulties related to eye closure, speech, chewing or emotional expression.

These changes can coexist and appear very differently from person to person.

Synchronicities: when one movement causes another that we don't want

Synkinesias are one of the most common sequelae after facial paralysis and can become particularly frustrating for those who experience them.

Imagine that you try to smile and, involuntarily, the eye on that same side begins to close. Or that, when you blink, you feel your mouth lift up. Perhaps, when you speak, you notice an excessive contraction in your chin or a tension that extends to your neck. These are examples of synkinesias.

What happens is that during facial nerve regeneration, some nerve fibers establish inappropriate connections. Thus, a command that should activate a particular muscle group ends up also activating other muscles.

Over time, these associated movements can become automatic and become integrated into everyday gestures and expressions.

But the impact goes far beyond the movement itself.

Imagine trying to smile naturally in a photograph and feeling your eye involuntarily close. Or being in a conversation and constantly being aware of the way your mouth is moving. Imagine avoiding certain expressions because you know they will trigger a contraction you can't control. For some people, these situations become a source of discomfort, insecurity, and frustration.

It is important to understand that synchronicities are not just an aesthetic issue. They can interfere with non-verbal communication, the expression of emotions, trust, and the way each person relates to others.

And they don't have to be very pronounced to have a significant impact.

It has been months or years already. Can I still improve?

Yes. One of the ideas that matters to demystify is the idea that, after a certain stage, there is no longer any possibility of evolution.

It is true that the process of facial nerve regeneration has its biological time limits and that spontaneous recovery can stabilize. However, this does not mean that the control of movements has reached its maximum potential.

The nervous system maintains its ability to adapt throughout life. Through neuroplasticity and appropriate motor training, it is possible to work on coordination, selectivity, and the quality of facial movements.

Even when synkinesias have been present for several years, specialized physiotherapy can help:

• Reduce the involuntary activation of certain muscles.
• Improve the ability to perform movements in a more selective manner.
• Reduce tension and the feeling of facial stiffness.
• Improve symmetry during expressions.
• Promote more natural and coordinated movements.
• Facilitate everyday tasks, such as speaking, eating, smiling, and blinking.

Naturally, the results depend on the characteristics of each case, the severity of the sequelae, and the therapeutic goals. It is not possible to guarantee a complete recovery, but it is possible to identify opportunities for improvement that have often not yet been explored.

It is never too late to seek specialized evaluation.

What is the role of physiotherapy in facial paralysis sequelae?

Specialized physiotherapy plays a fundamental role in the rehabilitation of people who suffer from facial paralysis. However, it is important to realize that treating a face with synkinesias is very different from working on the strength of the muscles.

The face has a very particular neuromuscular organization. Its movements are small, precise and highly coordinated. A smile, a blink of the eye or a movement of the lips involves a complex interaction between different muscles.

Therefore, the goal is not to exert more force, perform larger movements or repeat exercises indiscriminately. The goal is to improve control.

The current approach to specialized facial rehabilitation focuses on neuromuscular reeducation, seeking to teach the nervous system to produce more selective, coordinated, and functional movements.

1. Evaluate to understand what is really happening

Each person presents a different combination of sequelae. Therefore, before starting any intervention, it is essential to perform an individualized assessment.

In this evaluation, the physiotherapist observes:

• Facial symmetry at rest and during movement.
• The mobility and quality of muscle activation.
• The presence and distribution of synchinesias.
• The areas of greatest tension or contraction.
• The coordination between different muscle groups.
• The impact on daily functions, such as speaking, eating, drinking and closing the eyes.
• The difficulties and the goals identified by the person themselves.

Specific assessment instruments can be used, such as the Sunnybrook Facial Grading System, the Facial Disability Index (FDI), the FaCE Scale, and the Synkinesis Assessment Questionnaire (SAQ).

This analysis allows us to understand not only what the face is capable of doing, but also how it does it and what its perception is.

2. Neuromuscular reeducation: learning to move the face again

This is one of the central components of specialized physiotherapy.

Through specific and individualized exercises, the goal is to improve the ability to activate certain muscles without triggering involuntary movements in other regions.

For example, in a person who presents involuntary closure of the eye when smiling, the work could involve improving control of the smile while simultaneously reducing excessive activation of the ocular region.

The movement is performed progressively, with small, slow and controlled movements, respecting the individual's ability.

More than the amplitude of the movement, what matters is its quality.

3. Reduce tension and improve tissue mobility

Many people with facial paralysis describe a feeling of the face being stuck, heavy, or permanently contracted.

This tension can interfere with mobility and make movements less natural.

Physiotherapy can include gentle tissue mobilization techniques, relaxation strategies, and body awareness exercises, with the goal of improving comfort and facilitating the execution of more coordinated movements.

The intervention is always adapted to the needs and response of each party.

4. A exercise plan adapted to the reality of each person

Physiotherapy does not end at the session. When indicated, it is important that the person has an individualized program to perform at home, with exercises and strategies tailored to their condition.

It’s not about spending a lot of time in front of the mirror making faces or repeating movements until your muscles feel tired. It’s about integrating small, quality, consistent reeducation tasks into your daily routine.

The person must understand the purpose of each exercise, know how to perform it, and recognize when they are compensating or unnecessarily increasing tension.

Not all facial exercises help

For a long time, the rehabilitation of facial paralysis was often associated with strength exercises, exaggerated movements, and repetition of facial expressions.

However, the latest evidence and international consensus point to a different approach.

In the presence of sequelae, especially synchinesias, indiscriminate strength training can reinforce less selective activation patterns.

Therefore, practices such as repeatedly making grimaces, chewing on an elastic chewing gum to strengthen the face, or performing broad movements without specialized guidance are not generally recommended strategies.

Electrosurgery is also not recommended in the rehabilitation of facial paralysis, according to the international consensus of experts.

The most important thing is not to make more moves, but to learn how to make them better.

And when physical therapy is not enough?

The approach to facial paralysis sequelae can benefit from multidisciplinary intervention.

In certain situations, especially when there are more pronounced synkinesias, it may be useful to combine physiotherapy with other therapeutic options.

Botulinum toxin, for example, can be considered in selected cases, through evaluation by a physician with experience in this area. It allows temporarily reducing the activity of certain muscles, which can facilitate functional control and neuromuscular rehabilitation.

In specific situations, surgical approaches may also be considered.

It is important to emphasize that these options do not necessarily replace physical therapy. On the contrary, they can be complementary, with the collaboration of professionals being particularly important to achieve the best possible results.

Recovery also involves regaining confidence

There is a dimension of facial paralysis that is not always sufficiently valued: the emotional impact.

The face is a central part of our identity. Through it we communicate, smile, show surprise, sadness, joy, and so many other emotions.

When our mobility changes, it doesn’t just change the way we see ourselves in the mirror. It can also change the way we feel others see us.

There are people who stop liking photographs, who avoid smiling, who feel uncomfortable in social situations, or who are constantly concerned about their facial expression.

Others feel frustrated because they have already undergone so many treatments and still continue to experience limitations.

If you identify with any of these situations, we want to leave you a message: what you feel is valid and deserves to be heard.

Rehabilitation should not only focus on the muscles or on the symmetry of a photograph. It should look at the person, at their concrete difficulties, and at what they would like to be able to do again with confidence.

Sometimes, a small improvement in smile control, a reduction in tension when speaking, or the ability to keep the eyes open during an expression can represent a very significant change in everyday life.

What is the specialized facial paralysis therapy at Integrativa like?

In Integrative Medicine, facial paralysis-specific physiotherapy is based on an individualized approach, based on clinical evaluation and neuromuscular reeducation.

We accompany people at different stages of recovery: from recent cases of facial paralysis to people who have had sequelae for several months or years.

Each face has a history, an evolution, and its own needs. Therefore, we do not use the same exercise sequence for all people. We seek to understand the movement pattern of each face, identify the main limitations, and define realistic therapeutic goals.

The follow-up includes evaluation, individualized treatment, neuromuscular reeducation strategies, and guidance for working at home.

The sessions can also be held online, allowing for the monitoring of people who live far away or who, for various reasons, are unable to travel to the clinic.

Our commitment is to help each person reach their best possible functional potential, respecting their pace and needs.

There is still a lot to be done. And you don't have to go it alone. If you have facial paralysis and feel that you have never fully recovered, if your smile still looks different, if your eye involuntarily closes, or if you experience a constant feeling of tension in your face, know that it is worth seeking specialist evaluation.

Even though years have passed, there are strategies that can help improve coordination, reduce synkinesias, and make movements more natural.

We do not promise that the face will return exactly to what it was before. But we believe that recovery should not be considered complete just because time has passed.

Because recovery isn’t just about getting your face back into shape. It’s about feeling able to use it more freely, comfortably, and confidently again.

At Integrativa, we are available to accompany you on this journey. Learn more about the physiotherapy specialized in facial paralysis