TürkçeFacial paralysis in children is a clinical condition in which facial expressions cannot be controlled as a result of damage to or loss of function of the seventh cranial nerve, and successful outcomes can be achieved with early diagnosis and a multidisciplinary approach. This condition, which may be triggered by a wide spectrum of causes ranging from idiopathic processes to congenital developmental defects, should be managed in accordance with the principles of plastic and reconstructive surgery in order to minimize aesthetic and functional loss. Conservative protocols applied in the early period or dynamic reanimation techniques used in chronic cases play a critical role in restoring the child’s ability to smile, eye health, and social self-confidence, thereby making a healthy quality of life possible.
| What is facial paralysis in children? | Facial paralysis in children is the loss of movement on one side of the face or, rarely, on both sides, as a result of involvement of the facial nerve (7th cranial nerve), which controls the facial muscles. The most common type is peripheral facial paralysis (Bell’s palsy). |
| Who can develop it? | It can occur at any age, from newborns to adolescence. It may develop due to birth trauma, infections, or other causes. |
| Most common causes | Bell’s palsy (the exact cause is unknown), viral infections (Herpes simplex, Varicella zoster), middle ear infection, Lyme disease, birth trauma, head trauma, tumors, neurological diseases, and congenital anomalies. |
| Risk factors | A recent viral infection, ear infections, immune system diseases, head trauma, and certain neurological diseases may increase the risk. |
| Symptoms | Sudden weakness on one side of the face, drooping at the corner of the mouth, inability to close the eyelid completely, facial asymmetry while smiling, inability to wrinkle the forehead, drooling, changes in the sense of taste, and pain around the ear in some children may occur. |
| Eye-related symptoms | Because the eye cannot close completely, dryness, tearing, redness, a stinging sensation, and corneal damage may develop. Protecting the eye is an important part of treatment. |
| How quickly do the symptoms develop? | In Bell’s palsy, symptoms generally begin within hours and may reach their highest level within the first 24–72 hours. |
| How is it diagnosed? | Diagnosis is made through a detailed medical history and physical examination. When necessary, blood tests, imaging methods (MRI or CT), ear examination, and electrophysiological examinations may be performed. |
| Diseases evaluated in the differential diagnosis | Stroke (rare in children), Ramsay Hunt syndrome, Lyme disease, brain tumors, Guillain-Barré syndrome, chronic ear infections, and congenital facial paralysis should be evaluated. |
| Treatment | Treatment varies according to the cause. In some cases of Bell’s palsy, corticosteroid treatment may be considered. If an infection is present, appropriate antibiotics or antiviral medications may be used. Eye care and supportive treatment are important. |
| Eye care | Artificial tear drops, nighttime eye ointments, taping the eye when necessary, or protective closure methods may be applied. The aim is to prevent damage to the cornea. |
| Is physical therapy necessary? | Facial exercises and physical therapy may be recommended for some children. Rehabilitation may be beneficial in cases that persist for a long time or recover slowly. |
| Is surgical treatment required? | It is generally not required in Bell’s palsy. Surgery may be considered in specific situations caused by tumors, trauma, or congenital anomalies. |
| Recovery process | In the majority of children, especially those with Bell’s palsy, significant improvement is seen within weeks to several months. Most children recover completely. |
| Possible complications | Permanent facial muscle weakness, involuntary muscle movements (synkinesis), corneal damage due to dry eye, cosmetic asymmetry, and, rarely, permanent functional loss may develop. |
| When is urgent evaluation required? | Urgent evaluation is required if there is a change in consciousness, weakness in an arm or leg, speech disturbance, severe headache, double vision, high fever, signs of a severe ear infection, or facial paralysis that develops after trauma. |
| Points to consider at home | Protecting the eye, using medications regularly, paying attention to facial hygiene, performing the exercises recommended by the physician, and not missing follow-up visits are important. |
| Prevention methods | Timely treatment of middle ear infections, protection against Lyme disease in areas where ticks are present, completion of childhood vaccinations, and protection from head trauma may reduce the risk. |
| Prognosis | Although it varies depending on the cause, the prognosis in children is generally good. In particular, the great majority of children with Bell’s palsy show complete or near-complete recovery. |
What causes facial paralysis in children?
Understanding the origin of facial paralysis is the first step toward successful treatment. In some cases, the cause is completely unclear, while in others it results from external factors.
- Bell’s palsy
- Herpes Simplex virus
- Varicella Zoster virus
- Ramsay Hunt syndrome
- Lyme disease
- Middle ear infection
- Mastoiditis
- Parotid gland infections
- Temporal bone fractures
- Facial injuries
- Iatrogenic nerve injuries
Bell’s palsy, which we define as idiopathic, is the most common cause of facial paralysis in children. This condition is related to swelling and compression of the facial nerve due to various triggers while it passes through a narrow bony canal within the skull. Because the nerve remains under pressure within its own canal, it becomes unable to transmit signals from the brain to the facial muscles. Infectious processes are at least as common as this condition. In particular, agents such as the chickenpox virus or the herpes virus may reactivate at the ganglion points along the facial nerve and cause paralysis. In addition, an unnoticed tick bite during outdoor activities may cause facial paralysis due to Lyme disease. The anatomical structure of children creates a predisposition for middle ear problems to spread to the nerve.
What are the symptoms of congenital facial paralysis?
Congenital facial paralysis generally develops as a result of strain during birth or genetic factors related to the baby’s development in the womb. This condition must be distinguished from paralysis that occurs later in life.
- Trauma related to forceps use
- Pressure in the birth canal
- Moebius syndrome
- Sixth cranial nerve agenesis
- Seventh cranial nerve agenesis
- Congenital asymmetric crying facies
- Depressor anguli oris hypoplasia
- Cleft palate
- Hearing loss
- Limb anomalies
Paralysis caused by birth trauma is generally unilateral. Bruising may be seen on the baby’s face, especially around the temple or behind the ear. The good news is that a large proportion of these cases improve within the first few months without requiring any specific intervention. On the other hand, developmental defects such as Moebius syndrome require a much more careful approach. In babies with this syndrome, not only facial paralysis but also more extensive problems such as restricted eye movements and difficulty swallowing may be observed. During the diagnostic stage, observing the child’s facial movements while crying is highly valuable for making a differential diagnosis. In some babies, only one corner of the mouth does not move, which may indicate the simple absence of a muscle.
What clinical symptoms are seen in children with facial paralysis?
Facial paralysis is generally a condition that begins quite rapidly and suddenly. Families often notice severe asymmetry on one side of the child’s face when the child wakes up in the morning.
- Flattening of the cheek
- Drooping at the corner of the mouth
- Incomplete closure of the eyelid
- Leakage of liquids from the mouth
- Difficulty raising the eyebrow
- Inability to wrinkle the forehead
- Impaired sense of taste
- Asymmetry while smiling
- Inability to whistle
- Deviation of the lips
During the physical examination, the most distinguishing point for us is the extent to which the nerve is affected. In peripheral facial paralysis, one half of the face is completely affected. If the child cannot raise the eyebrows or wrinkle the forehead, it is certain that there is a problem along the nerve pathway. In central paralysis, however, the forehead muscles generally remain intact. This distinction is vitally important in determining whether the source of the paralysis is the brain or the nerve pathway. While monitoring the child’s facial movements, details such as how completely the eyes can close and how much difficulty the child has while eating provide us with preliminary information about the recovery process.
Which criteria are prioritized during the diagnostic process?
The diagnosis of facial paralysis is made by ruling out other systemic causes one by one. When paralysis begins in a child, the timing and course of the symptoms guide us regarding the direction in which we should proceed.
- House-Brackmann Grading
- Electroneurography
- Electromyography
- Contrast-enhanced MRI
- Temporal bone CT
- Lyme serology
- HSV PCR tests
- VZV serological tests
- Ear and parotid examination
- Pediatric neurology consultation
We frequently use the House-Brackmann scale to predict recovery potential. The third week of paralysis is a particularly critical turning point. If even the slightest movement is observed in the blinking reflex during this period, this is a strong sign that recovery will progress positively. In children who show no improvement or whose complete paralysis continues, we use ENG or EMG tests to determine the level of nerve damage. If the damage rate is very high, we must set aside the expectation of spontaneous recovery and consider surgical options. If there is an atypical onset during the diagnostic process, such as slow progression or bilateral paralysis, we must rule out other organic causes such as tumors.
Which pathologies do atypical clinical symptoms indicate?
Unfortunately, not every facial paralysis is a simple Bell’s palsy. Sometimes the body gives us a sign of a different problem.
- Parotid tumor
- Facial neuroma
- Cholesteatoma
- Metastatic masses
- Severe axonal transections
- Neuropathies
- Systemic leukemia
- Guillain-Barré syndrome
- Demyelinating diseases
- Multiple sclerosis
Paralysis that progresses gradually should always keep us alert. Rather than a sudden condition, a process that worsens over several weeks may suggest the presence of a mass compressing the nerve. In particular, a mass felt in the parotid gland, when combined with facial paralysis, must be examined immediately using radiological imaging. In bilateral paralysis, it is essential to investigate a systemic disease or neurological condition. Infections such as Lyme disease may reveal themselves through a characteristic rash and a history of tick bite. For us, the most important point is to proceed to the stage of surgery or advanced testing if no improvement is recorded within three months.
What is applied in conservative treatment?
In the acute period, meaning the first days of paralysis, the aim is to relieve the nerve. We try to prevent permanent damage by suppressing the swelling within the nerve canal.
High-dose systemic corticosteroids
- Prednisolone use
- Antiviral agents
- Acyclovir
- Famciclovir
- Artificial tear drops
- Eye moisturizing gels
- Sterile eye patch
- Neuromuscular training
- Mirror exercises
The first forty-eight hours of treatment are extremely valuable. If an infection is suspected, antiviral treatment must be added to corticosteroids. We must be careful when using steroids in children and inform the family about possible psychiatric side effects. Another important issue is eye health. When the child cannot close the eye completely, the cornea dries out, and this may cause serious damage. Therefore, protecting the eye with intensive tear drops and nighttime gels is an indispensable part of treatment. Mirror exercises and facial massages applied during the first months are effective in preventing problems such as synkinesis that may develop later.
What is synkinesis and how is it treated?
While facial paralysis is healing, the nerves may sometimes enter the wrong pathways and establish incorrect connections with the muscles. We call this synkinesis.
- Orbicularis oculi contractions
- Platysma contractions
- Mentalis muscle spasms
- Involuntary eye closure
- Crocodile tears
- Eye narrowing while smiling
- Involuntary facial movements
- Muscle contractures
- Intraoral cheek massage
- Botulinum toxin application
Synkinesis is the involuntary contraction of another muscle while the patient is performing a movement. For example, when the child wants to smile, the eye may close, or tears may flow while eating. To prevent this, physical therapy should not be neglected. If established synkinesis is present, our most effective solution in plastic surgery is Botulinum toxin. Microdoses applied to specific areas relax the involuntarily contracting muscles and balance the tense, asymmetric expression on the child’s face. These applications are not permanent and are planned as repeated sessions according to need.
What are the facial reanimation methods used in plastic surgery?
If months have passed since the paralysis and there is still no improvement, the muscles in the face are now considered “dead.” In this case, we proceed to surgical methods that will restore life to the muscles or transplant a muscle from another area.
Microneurovascular free muscle transfer
- Gracilis muscle flap
- Masseteric nerve transfer
- Cross-face nerve graft
- Temporalis muscle transposition
- Primary nerve repair
- Sural nerve graft
- Hypoglossal-facial anastomosis
- Static facial suspension
- Upper eyelid gold plate
Free muscle transfer is currently the gold standard. We transplant a thin muscle taken from the leg, the gracilis, together with its nerves and vessels to the paralyzed area of the face. In the postoperative period, thanks to brain plasticity, when the child clenches the teeth or uses that muscle, the newly transplanted muscle also begins to contract. Over time, this movement transforms into a natural smile, as though it were the face’s own muscle. If the patient is not suitable for microsurgery, we can also provide a solution by using the temporalis muscle in the temple area. By detaching this muscle from its original position and transferring it to the corner of the mouth, we can create a smile triggered by chewing movement.
What is dynamic reanimation surgery?
Dynamic reanimation is the most sophisticated procedure performed to restore movement to a paralyzed face. Our main objective is not only for the face to be symmetrical at rest but also to show active movement while speaking or smiling.
- Living muscle transfer
- Microsurgical nerve anastomosis
- Vascular connections
- Use of the masseteric nerve
- Imitation of a natural smile
- Functional symmetry
- Voluntary movement control
- Utilization of brain plasticity
- Long-term rehabilitation
- Continuous physiotherapy
The key to success in these operations is the strength of the muscle’s nerve connection. The masseteric nerve, meaning the chewing nerve, provides a very strong motor stimulus for the transplanted muscle. For a while after surgery, the child learns to smile by clenching the teeth. However, over time, the brain begins to perceive these signals as a natural smile command. This is more than surgery; it is an adaptation process. In two-stage nerve grafting procedures, we take an extension cable from the functioning nerves on the opposite side and transfer it to the paralyzed side. This is a more physiological method, but it requires two sessions.
How is the face corrected with static methods?
In some children, dynamic surgeries may be risky, or the family may be seeking a faster and less complex solution. In this case, static methods are lifesaving.
- Fascia lata suspension
- Synthetic suspension materials
- Upper eyelid weight
- Gold plate implantation
- Soft tissue suspension
- Preservation of facial symmetry
- Correction of lagophthalmos
- Passive eye closure
- Prevention of facial sagging
- Mechanical support
Static methods do not restore facial expressions, but they correct the drooping appearance at rest. In children whose eyes do not close, gold plate application is an excellent solution for preventing eye dryness. Thanks to gravity, the eyelid closes on its own. In suspension methods, we use tissues taken from the child’s own body or special threads to lift and secure the sagging parts of the face. These methods immediately improve the appearance of the face at rest and contribute positively to the child’s social self-confidence.
Why is the timing of surgical intervention so important?
In pediatric facial paralysis, timing is the most important instrument available to the surgeon. Incorrect timing may negatively affect the child’s developmental stages.
- The first thirty days are a critical period
- One-year follow-up period
- Preschool-period surgeries
- Planning between four and six years of age
- Preventing peer bullying
- Compatibility with language development
- Psychosocial preparation
- Nerve regeneration period
- Prevention of muscle atrophy
- Monitoring birth trauma
If there is a traumatic nerve transection, repair should be performed within the first month. Waiting causes the distal muscles to atrophy and the nerve endings to retract. In birth trauma, however, we must wait for one year because there is a 90% chance of spontaneous recovery. In children with Moebius syndrome or permanent paralysis, we prefer around 4–6 years of age, meaning the preschool period, for reanimation. An intervention performed during this period allows the child to have an appearance similar to peers when starting school. This is highly critical both for improving articulation and for the child’s psychological development.
How are anesthesia management and the syndromic approach handled?
The anesthesia process in operations involving children with Moebius syndrome, in particular, cannot be treated like a routine operation. These children require special preparation and a specialized team.
- Difficult airway assessment
- Planning for intubation difficulty
- Monitoring for malignant hyperthermia
- Multidisciplinary consultation
- Preoperative EMG analysis
- Identification of the motor donor nerve
- Emergency intervention protocols
- Anesthesia team preparation
- Pediatric neurology support
- Close postoperative monitoring
Because the jaw and facial structures of children with Moebius syndrome are different, unexpected difficulties may arise during intubation. Therefore, all equipment required for “difficult airway” management must be available in the operating room. Special preparation should also be made for rare but life-threatening conditions such as malignant hyperthermia. For us, performing the operation in a safe environment is as important as surgical success. Detailed electromyographic evaluations performed before surgery determine which nerve will be selected as the donor, and this directly affects the outcome of the surgery.
What should be expected during the rehabilitation process?
Our work does not end when the operation is completed; the real process begins at that point. Physical therapy is a part of surgery.
- Neuromuscular retraining
- Active mirror exercises
- Strengthening the cheek muscles
- Functional massages
- Speech therapy
- Lip-pursing exercises
- Articulation practices
- Voluntary smiling attempts
- Muscle stimulation
- Psychological support processes
Rehabilitation programs allow the muscle to integrate with the face. Learning to use the transplanted muscle is like a baby learning to walk; the brain constantly searches for and develops new signal pathways. Exercises performed under the supervision of a physiotherapist increase the strength and speed of muscle contraction. The family’s patience is very important during this process. Visible results generally begin to appear from the eighth month, and the muscle reaches full strength by the fifteenth month. During this long process, supporting the child’s self-confidence and keeping the child motivated are the most important emotional parts of treatment.
What is the chance of treatment at an older age?
As children with facial paralysis grow, their needs also change. Our approaches may differ slightly in older age groups.
- Revision surgeries
- Aesthetic refinements
- Contour corrections
- More detailed Botox applications
- Functional improvements
- Tissue transfers
- Psychosocial adaptation
- Strengthening communication skills
- Facial symmetry revision
- Permanent filler methods
The results of operations performed during childhood adapt better to the face as age progresses. However, when facial features become more defined during adolescence, minor asymmetries may become noticeable. During this period, we can perfect symmetry through small revisions or aesthetic refinements. The important point is that the functional capacity of the face has been preserved while the child grows. If the child learned a natural smile through reanimation at an early age, we achieve much more successful results during adolescence with aesthetic improvements alone. This journey is not merely a surgical procedure but a transformation that affects the child’s quality of life throughout life.
Why is neurological examination indispensable?
Facial paralysis is not merely an aesthetic problem; it may be part of an underlying systemic neurological condition. Therefore, neurology consultation is indispensable for us.
- Cranial nerve examination
- Reflex monitoring
- Motor strength analysis
- Assessment of sensory loss
- Balance and coordination
- Need for lumbar puncture
- Screening for systemic leukemia
- Screening for demyelinating diseases
- Assessment of developmental delay
- Genetic counseling
Some facial paralysis cases are part of much larger clinical conditions. For example, diseases such as leukemia or Multiple Sclerosis may present their first symptom as facial paralysis. If we focus only on the facial muscles during the examination, we may overlook other systemic warning signs. Therefore, working together with pediatric neurology protects both us and the family from major surprises. Genetic counseling should also be part of treatment in children who show developmental delay or different physical abnormalities. Evaluating the child as a whole with a scientific approach maximizes the success of treatment.
What advice is given to families after facial paralysis?
The treatment process is not limited to what is done in the hospital. The care shown by the family at home is one of the most important factors that accelerates recovery.
- Regular use of drops
- Nighttime eye patch
- Facial massage techniques
- Monitoring mirror exercises
- Regular follow-up visits
- Seeking psychological support
- A positive communication environment
- Nutritional habits
- Medication adherence
- Developmental monitoring
Families are generally very anxious, and this is completely natural. Our duty is to calm them and explain that the process is manageable. Regular use of drops is the most important task to be performed at home in order to protect eye health. Teaching massage techniques allows the family to participate actively in treatment. Keeping the child’s morale high at home directly affects the speed of recovery. In particular, celebrating the child’s success during mirror exercises increases self-confidence. When we act as a team, it is possible to overcome this process successfully.
What should aesthetic expectations be after surgery?
We must always be honest with our patients; perfect symmetry is not something that surgery can always guarantee. However, functional recovery changes life.
- Development of a natural smile
- Functional symmetry
- Balance at rest
- Vitality of facial expressions
- Protection of eye health
- Aesthetic improvement
- Social integration
- Increased self-confidence
- Quality of life
- Psychological relief
After surgery, our aim is for the child not to feel different when entering social environments. The smile may sometimes be slightly slower or subtler, but it is the child’s natural movement. Aesthetic expectations must be combined with surgical realities. Rather than making every detail of the face symmetrical, we try to achieve the child’s most natural appearance. Every face that functions well is socially successful. If the child can eat, speak, and those around the child can recognize the smile, then for us the success of the surgery is complete.
Why is a multidisciplinary approach necessary in pediatric facial paralysis?
Facial paralysis is not a problem that can be resolved by a single specialist. Cooperation among multiple disciplines is the cornerstone of treatment.
- Plastic surgeon
- Pediatric neurologist
- Ear, nose, and throat specialist
- Pediatric anesthesiologist
- Physiotherapist
- Ophthalmologist
- Speech therapist
- Genetics specialist
- Psychologist
- Pediatrician
Each discipline has a different perspective. While the ENT specialist treats the middle ear infection, the ophthalmologist monitors corneal health, and we plan the surgery for reconstruction of the face. This coordination ensures that no detail concerning the patient is overlooked. This approach is especially lifesaving in syndromic cases. A breakdown in communication is our greatest enemy during the treatment process. We come together at regular intervals, update the child’s treatment plan, and offer the best option at every stage.
Which modern surgical techniques stand out for facial paralysis in children?
As medical technology advances, the methods we use are evolving into techniques that leave fewer scars and allow faster recovery.
- Endoscopic reanimation
- Minimally invasive incisions
- Single-stage muscle transfers
- Navigation-guided nerve monitoring
- Advanced microsurgical equipment
- Natural nerve grafting
- Rapidly healing muscle flaps
- Functional Botox
- Advanced imaging techniques
- Computer-assisted planning
Today, we try to make incisions in areas that are as invisible as possible. By entering through the scalp or hidden folds in front of the ear, we can perform all procedures without disrupting the integrity of the face. Thanks to computer-assisted planning, we can calculate the position of the muscle with millimetric precision. These modern techniques both shorten the duration of surgery and make the child’s recovery process much more comfortable. With single-stage operations, we reduce the length of hospital stay and allow the child to return to the home environment more quickly.
What awaits us in the future of facial paralysis treatment?
In the future, I expect facial reanimation to be performed using much more personalized methods supported by advanced technology.
- Stem cell treatments
- Nerve regeneration support agents
- Artificial nerve sheaths
- Genetic treatment approaches
- Tissue production with 3D printers
- Smart nerve conduction devices
- Biological adhesives
- Tissue engineering solutions
- Digital simulation monitoring
- Faster nerve healing
Stem cell research appears likely to increase the capacity of nerves to regenerate. Artificial sheaths used in nerve repairs will help the nerve reach the correct target more accurately. Producing tissue or support units specifically for the individual child using 3D printing technology will increase surgical precision. The most exciting development for us is the use of biological support agents that accelerate nerve healing. These developments will completely transform the treatment of facial paralysis and significantly shorten recovery periods.
What is the main message families should know about facial paralysis in children?
Finally, the most important thing I want to say to families facing this condition is that they should not lose hope. Facial paralysis is a condition that can be corrected and treated.
- Early diagnosis is vital
- Patience is necessary
- Do not neglect physiotherapy
- Pay attention to eye health
- Maintain communication with your physician
- Do not avoid psychological support
- Remain hopeful
- The process is a long journey
- Speak openly with your child
- Success is teamwork
Facial paralysis may darken the family’s world for a while, but we are here. When science, surgery, and patience come together, the results are always encouraging. When you see your child’s first smile, you will feel that all the difficulties you endured were more than worthwhile. The important point is to manage the process correctly and proceed with the right specialists at every step.
Frequently Asked Questions
He completed his medical education at Ankara University Faculty of Medicine in 1996 and his specialty training between 1996–2002 at Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery.
Between 2002–2009, he worked at Süleyman Demirel University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery.
Since 2009, he has been working at Hacettepe University Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery. He received the title of Associate Professor in 2011. Dr. Nasır became a Professor in 2019 and continues to work as a faculty member in this position.
Between 2006–2008, he conducted studies on composite tissue transplantation at the Cleveland Clinic in Ohio, USA, together with Dr. Siemionow, who performed the first face transplant in the United States and the second in the world.
In 2012, he successfully performed Turkey’s second face transplant, which was the third among full face transplants in the world and the 22nd overall. Simultaneously with this face transplant, the world’s first quadruple limb transplant was carried out at Hacettepe University by a large team under his leadership.
He won second-place awards in the experimental and clinical specialist competitions at the 31st and 32nd National Plastic, Reconstructive and Aesthetic Surgery Congresses. In 2023, he completed his doctorate in Hand Surgery at Hacettepe University Faculty of Medicine.
He is a member of the American Society of Reconstructive Microsurgery, Plastic Surgery Research Council, Turkish Society of Plastic, Reconstructive and Aesthetic Surgery, Reconstructive Microsurgery Association, and Turkish Society for Surgery of the Hand and Upper Extremity.
