TürkçeFacial paralysis after salivary gland surgery is muscle weakness and loss of movement that occurs when the facial nerve, which passes directly through the parotid gland located in front of the ear, is affected during the surgical treatment of tumors or masses arising in this gland. In parotidectomy operations, which are among the most delicate procedures in the head and neck region, this condition develops when the electrical transmission to the main nerve network controlling our facial expressions is interrupted while the diseased tissue is being removed. Also known as facial paralysis, this condition is characterized by a disruption in the biological communication between the brain and the facial muscles and is an important clinical complication requiring direct intervention after surgery.
| What is facial paralysis after salivary gland surgery? | It is the development of loss of movement or weakness on one side of the face due to involvement of the facial nerve, which moves the facial muscles, after salivary gland surgery, particularly surgery of the parotid gland located in front of the ear. This condition may be temporary or permanent. |
| Why does it occur? | It may develop as a result of stretching of the facial nerve during surgery, compression caused by edema, manipulation of the surrounding tissues, partial damage to the nerve, or the inability to preserve the nerve because the tumor is close to or has invaded the nerve. |
| After which operations can it occur? | It is most commonly seen after parotid gland surgery. Although certain branches of the facial nerve may be affected during submandibular salivary gland surgery, complete facial paralysis is less common. |
| What is temporary facial paralysis? | It is a loss of function caused by edema or stretching during surgery despite preservation of the nerve structure. Improvement is seen within weeks or months in most patients. |
| What is permanent facial paralysis? | It is permanent loss of function that develops when the nerve is severely damaged or when the nerve must be removed because of the tumor. Recovery may be limited, and advanced treatments may be required. |
| Symptoms | Drooping of the corner of the mouth, inability to close the eye completely, asymmetry when smiling, inability to wrinkle the forehead, weakness in lip movements, leakage of food and liquids from the corner of the mouth while eating, and mild speech impairment may occur. |
| Which facial movements may be affected? | Voluntary facial movements such as raising the eyebrows, closing the eyes, moving the nostrils, smiling, pursing the lips, and puffing out the cheeks may be affected. |
| How is the diagnosis evaluated? | The function of the facial muscles is evaluated through postoperative neurological and physical examination. When necessary, nerve function may be assessed with tests such as electromyography (EMG). |
| Recovery time | In temporary nerve involvement, recovery may vary from several weeks to several months. The healing time of the nerve depends on the degree of damage and may take longer in some cases. |
| Treatment approach | Treatment is planned according to the degree of nerve damage. Eye protection, physical therapy, facial exercises, and medication when considered necessary may be applied. Reconstructive surgical options may be evaluated in cases of permanent damage. |
| Why is eye care important? | If the eye cannot close completely, the cornea may become dry and damaged. Therefore, artificial tear drops, eye ointments, and closing the eye at night when necessary may be recommended. |
| Physical therapy and rehabilitation | Facial exercises and rehabilitation programs may be applied to support the coordination of the facial muscles, reduce muscle stiffness, and help restore function. |
| Possible complications | Permanent facial asymmetry, involuntary muscle movements (synkinesis), dry eye, corneal damage, difficulties with speech and eating, and psychological effects may develop. |
| When should a doctor be consulted? | Evaluation is required if unexpected worsening of facial movements, severe dry eye, eye pain or changes in vision, redness or discharge at the wound site, fever, or severe pain develops. |
| What should be considered at home? | It is important not to neglect eye care, to follow the care instructions for the surgical area, to perform the recommended facial exercises regularly, to use medications in accordance with the prescription, and not to miss follow-up appointments. |
| Prognosis | The prognosis depends on the degree of nerve damage and the reason for the surgery. If the nerve is only temporarily affected, the likelihood of recovery is high. Permanent loss of function may occur when the nerve is severely damaged or removed, and additional treatments may be required. |
Why Does Facial Paralysis Occur After Salivary Gland Surgery?
To fully understand the causes of facial paralysis, it is very helpful to visualize the anatomy of the region. You can think of the facial nerve as a large tree whose trunk emerges from behind the ear and whose branches spread to every corner of the face. The salivary gland is like a mass of soil surrounding all the branches of this tree. During surgical intervention, the diseased mass inside that soil must be removed without causing any damage to the roots or branches of the tree.
Today, special nerve monitors that provide audible and visual information about the location of the nerve during surgery are used to perform this procedure safely. Anatomical landmarks are also followed with great care. However, some tumors may completely surround the nerve, adhere to it, or grow into the nerve tissue. Human anatomy is not always standard as illustrated in textbooks; the pathways of nerves may vary considerably from person to person. Since saving the patient’s life and completely removing the tumor are always the highest priorities, these branches may be stretched, exposed to pressure, or necessarily cut and removed together with the tumor during surgery. In such situations where nerve transmission is interrupted, the facial muscles become unable to receive movement commands from the brain.
Is Facial Paralysis After Salivary Gland Surgery Temporary or Permanent?
When asymmetry or immobility is observed in the patient’s face during the postoperative period, the first issue evaluated is the degree of permanence of the condition. Symptoms of facial paralysis may appear in a significant proportion of patients during the early period. However, the vast majority of these symptoms result from the nerve losing its function only temporarily.
Nerve tissue is highly sensitive to contact, traction, or minimal temperature changes caused by medical instruments during surgery. Think of electrical cables; the outer plastic protective sheath remains completely intact, but the wires inside become temporarily unable to conduct current. This temporary paralysis, known as neuropraxia in the medical literature, completely improves over several months as the nerve gradually repairs itself. This recovery process generally extends over a period of three to nine months.
Permanent facial paralysis occurs when the nerve is completely invaded by the tumor and must be cut. Even in operations performed by expert hands, this risk exists to a certain extent. When the nerve is completely severed, brain commands can never reach the muscles because the communication pathway is irreversibly interrupted. Another interesting situation may sometimes occur during the healing process. As severed or damaged nerve fibers attempt to regrow, they may lose their way. Nerve endings that would normally activate the salivary gland and produce saliva may connect to the sweat glands beneath the skin. In such a case, involuntary redness and sweating occur on the patient’s cheek while eating. This condition emerges as a specific syndrome that considerably affects the daily lives of patients.
With Which Symptoms Does Facial Paralysis After Salivary Gland Surgery Manifest?
Facial paralysis is not only an aesthetic concern; it is also a highly challenging process that deeply affects many basic bodily functions of the patient. When the facial muscles lose their ability to move, many anatomical regions become unable to perform their functions.
The main problems observed are as follows:
- Lagophthalmos
- Saliva leakage
- Speech disorder
- Difficulty chewing
- Facial asymmetry
- Loss of sensation
The effects of these symptoms on daily life are extremely significant. The condition known as lagophthalmos is the inability of the patient to close the eye completely. When the eyelid remains open, the cornea, which is the transparent front surface of the eye, is continuously exposed to air and becomes dry. Over time, this dryness may lead to severe infections and vision loss and is therefore a dangerous condition.
Paralysis of the muscles around the mouth causes the lower lip and cheek area to droop downward. The patient experiences leakage when drinking liquids. Pronunciation of letters produced by bringing the lips together becomes particularly difficult, and speech begins to become unclear. Food accumulates between the cheek and teeth while eating. One of the most devastating effects is aesthetic loss. Smiling is one of the most fundamental ways people communicate with the outside world, and losing this expression may cause patients to withdraw from their social environments and become isolated.
What Is the Role of Plastic Surgery in the Treatment of Facial Paralysis After Salivary Gland Surgery?
The primary responsibility of head and neck surgeons is to remove the tumor and protect the patient’s health. After this vital task has been completed successfully, the process of rebuilding the patient’s quality of life begins. Restoring facial symmetry when looking in the mirror, regaining the smile, and repairing basic functions constitute a highly specialized field managed by plastic and aesthetic surgery specialists.
This revitalization process is called reanimation. Plastic surgery not only aesthetically restores the external appearance of the face but also reconnects severed cables at a microscopic level. When necessary, muscles and nerves are transferred from other parts of the body to recreate the impaired biomechanics of the face. This treatment process is not a standard package; it is planned through a completely personalized algorithm according to when the patient applies for treatment, how much time has passed since the paralysis, and the current condition of the muscles.
How Is Facial Paralysis Repaired in the Early Period After Salivary Gland Surgery?
If it is known that the facial nerve was sacrificed during surgery because of the condition of the tumor, the most appropriate approach is to repair the nerve without delay, preferably during the same operation or within the first thirty days. The importance of this critical period arises from the fact that the facial expression muscles are still viable and waiting for a signal from the brain.
The most basic method applied during the early period is directly suturing the severed nerve endings together under a surgical microscope. This is not an ordinary suturing procedure; only the outer sheath of the nerve is carefully joined using sutures much thinner than a human hair. However, for healing to occur, there must be absolutely no tension in the sutured area. If tension is present, nerve cells cannot grow across to the other side. If a large amount of tissue has been removed together with the tumor and there is a gap between the two nerve ends, an extension cable must be placed between them.
The main nerve grafts used are as follows:
- Great auricular nerve
- Sural nerve
The great auricular nerve provides sensation to the neck and earlobe and can be easily identified and used because it is very close to the surgical field. When a segment is taken from this area, some loss of sensation may occur around the earlobe, but this is a small price to pay for restoring facial movement. When a longer extension cable is required or many nerve branches need to be repaired, the sural nerve taken from the back of the leg is used. Since this nerve has a very long structure, it can extend from one end of the face to the other and causes only a small loss of sensation around the heel without affecting walking in any way.
Which Nerve Transfers Are Performed Within One Year in Cases of Facial Paralysis After Salivary Gland Surgery?
If several months have passed since the paralysis but one year has not yet elapsed, the facial muscles gradually begin to weaken, but they are still alive. If the severed main nerve root cannot be used, plastic surgery specialists must find a “different electrical source” from another part of the body to reactivate the facial muscles. The procedure of taking a healthy nerve and connecting it to the paralyzed nerve is called neurotization or nerve transfer.
The main methods applied are as follows:
- Masseteric nerve transfer
- Cross-face nerve grafting
- Dual-innervation transfer
The masseteric nerve, which activates our chewing muscle, has the capacity to carry very powerful electrical signals. This nerve is identified within the cheek and connected to the paralyzed facial nerves using microsurgical methods. When the nerve heals several months after the operation, the facial muscles work and the patient smiles when the patient lightly clenches the teeth. Over time, through the brain’s capacity to learn and physical therapy, the patient learns to smile naturally without thinking about clenching the teeth.
In cross-face nerve grafting, the aim is to transfer electrical signals from the functioning facial nerves on the healthy side to the paralyzed side through a cable. A nerve graft taken from the back of the leg is passed through the inside of the upper lip to create a bridge between the healthy side and the paralyzed side. The greatest advantage of this method is that the command comes directly from the smile center on the healthy side. This allows the patient to produce an emotional and completely spontaneous smile. In some cases, the advantages of these two methods may be combined in a repair known as dual innervation.
How Are Muscle Transfers Applied When One Year Has Passed Since Facial Paralysis After Salivary Gland Surgery?
As time progresses, especially after more than one year, muscle tissue loses its ability to remain viable while waiting. Facial expression muscles that receive no signals from the brain begin to atrophy, their structures deteriorate, and they are replaced by hard connective tissue. At this point, even if the electrical cable is repaired, there is no longer a functioning bulb at the end. Plastic surgery specialists must then transfer completely new and functioning muscle tissue to the face.
The preferred muscle tissues are as follows:
- Gracilis muscle
- Temporalis muscle
One of the most ideal spare muscles in the body is the gracilis muscle located on the inner side of the thigh. This muscle can be safely removed from the leg without impairing walking or running. The surgeon completely frees this muscle together with its own artery, vein, and nerve and transfers it to the face. Under a microscope, these vessels are sutured to the facial vessels with millimetric precision, and blood flow to the muscle is restored. The nerve of the muscle is generally connected to the chewing nerve. Adapting this muscle to its new location, enabling it to begin contracting, and helping the patient relearn how to smile require a meticulous rehabilitation process extending over several months.
For elderly patients or patients who are unable to tolerate prolonged microsurgical operations, the temporalis muscle in the temple area is used. A portion of this muscle is released from its original location, shifted toward the corner of the mouth, and sutured into place. This procedure, which does not require vascular repair, takes much less time. Each time the patient clenches the teeth, this muscle pulls the corner of the mouth upward and provides functional correction of the asymmetry.
How Is Facial Hollowing Associated With Facial Paralysis After Salivary Gland Surgery Corrected?
The salivary gland is not only a secretory organ but also a full tissue structure that occupies a considerable volume between the cheek and the ear. When this gland is surgically removed, a visible space and depression remain behind. The failure of the muscles to function is not the only cause of facial asymmetry; there is also a volumetric loss. While facial movements are restored through dynamic repairs, correcting this anatomical depression is also extremely necessary to achieve aesthetic integrity.
The main aesthetic procedures applied are as follows:
- Autologous fat injection
- Barbed thread lifting
Autologous fat injection is a procedure involving a natural filler material obtained from the patient’s own body. Fat cells, generally harvested from the abdomen or around the waist using thin cannulas, are purified through special processes. These valuable cells are then injected back into the hollow area where the salivary gland was removed using microinjectors. These cells not only provide volume but also significantly improve the quality, brightness, and elasticity of the skin in that area through the stem cells they contain.
When muscle or nerve transfer is performed to the face, these new structures require time to heal and begin functioning. During the early period, these tissues may sag under the effect of gravity, and the delicate sutures may be damaged. To prevent this, the cheek is suspended upward with special barbed threads placed beneath the tissue. These threads reduce the load on the transferred tissue during the recovery period and provide a major source of encouragement by allowing the patient to see that facial sagging has improved immediately after surgery.
How Does Facial Paralysis After Salivary Gland Surgery Affect Eye Health and How Is It Protected?
One of the most dangerous consequences of facial paralysis, and perhaps one requiring the most urgent intervention, is the inability of the eyelids to close. Even while sleeping, the eyelid remaining partially open deprives the eye of its protective tear film. If precautions are not taken, this dryness may lead to wounds on the corneal surface, infections, and ultimately vision loss.
The methods applied to protect eye health are as follows:
- Gold plate placement
- Tarsorrhaphy
- Eyebrow suspension
The most commonly applied and highly effective method is the placement of a small gold plate inside the upper eyelid. Gold is highly compatible with the human body and does not cause allergies. This plate, specially selected according to the weight of the patient’s eyelid, is concealed inside the eyelid under local anesthesia. When the patient attempts to close the eye and the muscle keeping the eye open relaxes, the weight of the gold works with gravity to pull the upper eyelid downward and allows the eye to close completely, even if passively. Tightening procedures that correct lower eyelid drooping and lifting of the descended eyebrows are other important surgical steps that preserve function around the eye.
How Are Involuntary Movements Seen After Facial Paralysis Following Salivary Gland Surgery Treated?
The recovery period of paralyzed nerves may not always follow a perfect map. Healing fibers may connect to the wrong muscle groups and cause confusion in communication. For example, a nerve ending that should control lip movements may connect to the muscles around the eye during healing. In this case, when the patient only wants to smile, the eye closes tightly and involuntarily. This simultaneous contraction is called synkinesis.
The methods applied to control synkinesis are as follows:
- Botulinum toxin injection
- Balancing the muscles on the opposite side
Botulinum toxin, which is more commonly known for cosmetic purposes among the public, is a unique medical tool in the treatment of facial paralysis. Plastic surgery specialists inject minimal doses into targeted muscles, temporarily interrupting the communication of muscles that function incorrectly and contract involuntarily. In this way, the patient’s eye does not close while smiling.
In addition, while the paralyzed side of the face remains completely weak, the healthy side continues to function with full strength. This overwhelming pulling force on the healthy side makes facial asymmetry and deviation of the mouth much more pronounced. Small doses are also injected into the excessively active muscles on the healthy side to slightly weaken their pulling force. In this way, the strength of both sides of the face is balanced, and the harmonious, balanced asymmetrical expression of the face is restored even at rest.
How Is Scar Care Performed in the Treatment of Facial Paralysis After Salivary Gland Surgery?
Major salivary gland surgery and any subsequent reconstructive operations necessarily require incisions to be made in the skin. When planning the incisions, surgeons take maximum care to follow aesthetic principles by concealing the scars within the folds of the ear, inside the hair-bearing scalp, or along the natural lines of the neck. However, every person has a different genetic wound-healing potential. In some individuals, surgical scars may tend to heal as raised, red, and firm tissue.
The methods used for scar management are as follows:
- Use of silicone sheets
- Scar massage
- Laser applications
Early scar care begins once the wound edges have healed after surgery. Silicone gels and silicone sheets covering the scar keep the wound area moist and suppress excessive scar tissue production. Special massage techniques taught to patients help soften the tissue and allow it to flatten to skin level. If the scar remains bothersome despite all these efforts, fractional laser devices are used to lighten its color and help it integrate completely with the surrounding skin tissue.
The process of facial paralysis developing after salivary gland surgery is undoubtedly a long and exhausting journey for patients, both physically and emotionally. However, thanks to the extraordinary repair techniques offered by modern microsurgery and personalized approaches planned with correct timing, this condition can be completely reversed. Repairing severed nerves with sutures thinner than a strand of hair, transferring new muscles from different regions to the face, and restoring aesthetic fullness using the patient’s own natural tissues make it possible to smile again.
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.
