TürkçeCold weather, freezing winds, and sudden drops in temperature can directly trigger facial paralysis. Our face, which is the part of the body most exposed to external factors, experiences a regional shock when it is exposed to low temperatures without protection. Especially during the winter months, going outside with wet hair, being exposed to severe frost, or being directly exposed to drafts suddenly slows blood flow around the face. This rapid circulatory disturbance reduces tissue oxygenation, leaving the nerves vulnerable to infections and creating the conditions for opportunistic viruses to reactivate. As a result, environmental cold stress causes sudden damage to the nerve network that controls our facial muscles, significantly increasing the risk of facial paralysis.
| Relationship Between Facial Paralysis and Cold Weather | It has not been conclusively proven that cold weather alone causes facial paralysis. However, sudden exposure to cold is thought to trigger mechanisms that may affect the facial nerve in some individuals. |
| Most Common Type of Facial Paralysis | The most common cause of peripheral facial paralysis is Bell’s palsy. In this condition, the facial nerve is affected, and sudden weakness or paralysis may develop in the muscles on one side of the face. |
| Possible Effect of Cold Weather | Cold weather may contribute to the constriction of blood vessels and temporarily affect circulation around the facial nerve. However, this relationship is not definitive, and a direct cause-and-effect relationship cannot be established on its own. |
| Role of Viral Infections | The reactivation of certain viral infections, such as the herpes simplex virus, is thought to play an important role in the development of Bell’s palsy. |
| Risk Factors | Diabetes, pregnancy, upper respiratory tract infections, certain immune system-related conditions, and a previous history of facial paralysis 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, asymmetry when smiling, changes in the sense of taste, pain around the ear, and dry eyes may occur. |
| How Quickly Do Symptoms Develop? | Symptoms generally begin within hours and often reach their most pronounced level within 48–72 hours. |
| Exposure to Cold Wind | Although prolonged exposure to strong winds or low temperatures has been suggested as a possible trigger in some individuals, there is no strong scientific evidence that conclusively confirms this. |
| Prevention Methods | Protecting the head and face appropriately in cold and windy weather, supporting general health, and taking care to avoid infections may be beneficial. |
| How Is the Diagnosis Made? | The diagnosis is made through the patient’s medical history, physical examination, and neurological evaluation. Additional tests may be requested when necessary to rule out other underlying causes. |
| Treatment | In Bell’s palsy, corticosteroid treatment may be administered during the early period in suitable patients. Antiviral medications may also be considered in some cases. The treatment plan is determined by the physician. |
| Eye Protection | If the eyelid cannot close completely, artificial tear drops, eye ointments, and covering the eye when necessary are important for preventing corneal damage. |
| Physical Therapy | Facial exercises and physical therapy applications may contribute to the recovery process in some patients. |
| Recovery Time | In most patients, symptoms begin to improve within weeks, and significant recovery may be observed within several months. Recovery time may vary from person to person. |
| Risk of Permanent Damage | Although most patients recover completely or to a large extent, mild muscle weakness, involuntary muscle movements, or facial asymmetry may remain permanent in some individuals. |
| Should Not Be Confused with Stroke | If sudden facial paralysis occurs together with symptoms such as weakness in the arm or leg, speech impairment, changes in consciousness, or loss of balance, the possibility of stroke should be considered and urgent medical evaluation should be performed. |
| When Should a Healthcare Facility Be Consulted? | When sudden facial muscle weakness, drooping on one side of the face, inability to close the eye, or any symptom suggestive of facial paralysis appears, a healthcare facility should be consulted without delay. |
How Do Cold Weather and Sudden Temperature Changes Anatomically Affect Facial Paralysis?
To understand the relationship between facial paralysis and cold weather, as well as its mechanism of development, it is necessary to understand the challenging pathway followed by the facial nerve. While many other nerves in the human body are surrounded by flexible soft tissues and fat pads that can absorb pressure, our facial nerve is trapped inside a tunnel within the skull called the “Fallopian canal,” which is completely surrounded by hard bone. This tunnel is so narrow that there is almost no space around the nerve.
When our body is exposed to cold, it reflexively constricts the superficial blood vessels to preserve the temperature of the internal organs. Especially during the winter months, going outside before the hair has completely dried after bathing or being exposed to cold wind while sweating causes heat loss from the skin to become much faster and more severe due to the effect of evaporation. This sudden constriction of the blood vessels also directly affects the capillaries that nourish the nerve inside the bony tunnel. When the nerve tissue cannot receive sufficient blood and oxygen, it becomes structurally stressed.
At this exact point, weaknesses in the immune system come into play. When immunity decreases locally, viruses become active and initiate inflammation in the nerve sheath. Like every inflamed tissue, the nerve sheath tends to retain water and swell, meaning that edema develops. However, the hard bony walls surrounding it do not allow this. The increasing pressure inside begins to compress the nerve itself. This situation resembles the thin wires inside an electrical cable being crushed after a heavy vehicle passes over it, preventing the electrical current from being transmitted. The brain sends commands such as “smile,” “close your eye,” or “raise your eyebrow,” but these commands cannot pass through the compressed area and reach the facial expression muscles.
The main motor branches of the facial nerve are as follows:
- Temporal branch
- Zygomatic branch
- Buccal branch
- Marginal mandibular branch
- Cervical branch
Each of these branches moves a different area of the face. Because the compression occurs in the main trunk, the energy going to all these branches is interrupted, and that half of the face becomes completely immobile.
What Are the Symptoms of Facial Paralysis That Occurs in Cold Weather?
The body gives certain very clear signals immediately before or during the development of facial paralysis. Most often, patients notice the condition when they look in the mirror after waking up in the morning or when liquids spill from the corner of the mouth while drinking something at breakfast.
The most common symptoms are as follows:
- Visible facial asymmetry
- Downward drooping at the corner of the mouth
- Inability to close the eye
- Inability to wrinkle the forehead
- Extreme sensitivity to sound
- Impairment of the sense of taste
- Severe pain behind the ear
There are very logical anatomical reasons for the appearance of these symptoms. For example, pain behind the ear is the first physical reflection of inflammation and edema inside the bone. Most patients feel a dull pain radiating to the neck and behind the ear several days before the paralysis fully develops. The reason for extreme sensitivity to sound is that the facial nerve also controls a small muscle inside the ear called the stapedius muscle. When this muscle becomes paralyzed, it cannot perform its function of softening loud sounds, and sounds are perceived by the patient as echoing or excessively loud. Likewise, because the facial nerve also carries the sense of taste from the front part of the tongue, patients state that the taste of food becomes metallic or disappears completely.
What Should Be Done During the First Hours When Facial Paralysis Develops?
From the moment numbness, a feeling of heaviness, or an obvious deviation is noticed on one side of the face in the mirror, a race against time begins. The first 24 to 72 hours in particular are extremely valuable for preventing the damage occurring in the nerve from turning into permanent physical destruction. The primary goal during this acute period is to rapidly suppress the swelling inside the narrow bony tunnel and eliminate the crushing pressure on the nerve as soon as possible.
During this critical period, patients must apply to an emergency department or a neurology specialist without delay. In the early period, high-dose corticosteroid treatments are generally used together with antiviral medications to stop viral replication. These aggressive medical treatments, when started quickly, reduce the edema in the outer sheath of the nerve and prevent the cables called axons, which pass through it and provide the actual transmission, from being severed. If the edema does not resolve rapidly, these delicate cables under pressure physically break, and the nerve sustains damage that is very difficult to reverse. Approximately eighty to ninety percent of patients who receive early and appropriate intervention recover completely within months without any noticeable residual effects. However, permanent damage may unfortunately develop in the remaining group.
How Is the Extent of Damage Classified in Facial Paralysis?
An international system is used in medicine to objectively evaluate the severity of nerve damage, predict the patient’s recovery potential, and determine the future treatment plan. Although every patient’s face may appear drooped from the outside, the extent of cellular damage may differ greatly.
The degrees of damage are as follows:
- Mild damage
- Moderate damage
- Severe damage
In mild damage, there is no cellular interruption. There is only a temporary state of “stunning” or “conduction block” in the nerve due to momentary pressure. The main trunk of the nerve, the internal fibers, and the protective sheath remain completely intact. Patients in this condition usually return completely to their previous state within a few days to several weeks. No additional surgical intervention is required.
In moderate damage, injury and localized breaks begin to occur in the internal cables that provide conduction, known as axons. However, the outer protective sheath that holds the nerve together remains intact. Preservation of the protective sheath is a great advantage because the recovering nerve fibers can travel through this sheath like a tunnel and reach the correct facial muscles again. Recovery takes several months in these cases.
In severe damage, unfortunately, both the internal cables are completely severed and the protective sheath is seriously fragmented. Commands from the brain can no longer reach the facial muscles in any way. The possibility of spontaneous recovery is almost nonexistent. Permanent consequences such as very pronounced facial asymmetry, the eye remaining completely open, and fluid leakage from the corner of the lips while speaking become established.
When Should Plastic Surgery Be Involved in Cases of Permanent Facial Paralysis?
For patients who show no signs of recovery despite the passage of months after facial paralysis and who develop permanent damage, applying to a Plastic and Aesthetic Surgery Specialist at the correct time is vitally important so that they can regain their functional abilities and aesthetic appearance. The most fundamental rule determining success in plastic surgery approaches is “proper management of time.”
The muscles in the human body preserve their vitality and volume through electrical signals coming from the nerves to which they are connected. When the facial nerve is severed or permanently blocked, the facial expression muscles are completely deprived of these vital signals. If a muscle receives no nerve stimulation for an average of eighteen months, the muscle cells begin to die irreversibly and are replaced by nonfunctional connective tissue or fat tissue. This condition is called muscle wasting, or complete atrophy.
After this very critical eighteen-month threshold has been exceeded, no matter how perfectly a nerve transfer surgery is performed to correct facial paralysis, the operation will not work because no living muscle remains to be stimulated by the electrical current and contract in response. Therefore, patients who do not respond to medical treatments within the first six months should be evaluated for reconstructive surgery without delay. Interventions performed during the early period, while the patient’s own facial expression muscles are still alive, produce much more natural and successful results.
How Is the Problem of Inability to Close the Eye Due to Facial Paralysis Treated?
The eyelids are where permanent facial paralysis stops being merely a cosmetic problem for the patient and becomes a very serious emergency. When the circular muscle that closes our eye like a zipper becomes paralyzed, the upper eyelid cannot move downward, while the lower eyelid droops and turns outward under the effect of gravity. The condition in which the eye remains open is called lagophthalmos in medical terminology. Because the blinking reflex is lost, the transparent outer layer of the eye, the cornea, constantly comes into contact with air, dust, and wind and becomes dry. This is an extremely dangerous process that may begin with severe stinging and burning and progress to corneal perforation and permanent blindness.
Methods used in plastic surgery to protect eye health are as follows:
- Gold weight implantation
- Temporalis muscle transposition
- Tarsorrhaphy procedure
- Lower eyelid suspension techniques
Gold weight implantation is a highly practical and equally effective method. A tiny plate made of pure gold, with its weight specially adjusted according to the patient’s needs, is placed inside the upper eyelid immediately beneath the skin. Because pure gold is fully compatible with the body, it does not cause a reaction and is quite heavy despite its small size. Under the effect of gravity, this gold plate pulls the eyelid downward even when the muscles are not functioning and allows the eye to close completely while sleeping or attempting to blink.
In temporalis muscle transposition, more active eyelid closure is targeted. A portion of the temporal muscle, which is independent of the facial nerve and is known as a chewing muscle, is tunneled beneath the skin and placed into the eyelids. When the patient lightly clenches their teeth, the eyelids close actively. In this way, a movement similar to complete recovery of muscle stimulation can be achieved. In elderly patients, the outer edges of the eyelids may be joined with a small suture to reduce the exposed surface area of the eye.
How Is the Ability to Smile Restored in Early-Stage Facial Paralysis?
One of the greatest goals in facial paralysis treatment is not only for the patient to look normal when staring motionlessly into the mirror, but also for the face to move symmetrically while speaking, feeling happy, and smiling. If less than one year has passed since the facial paralysis, the patient’s own facial expression muscles are still alive. In these early-stage cases, other healthy motor nerves in the body are used as an alternative power source to replace the nonfunctioning facial nerve.
This procedure requires extremely delicate microsurgical techniques. The masseteric nerve, a very strong nerve that performs the act of chewing, is most commonly used. During the operation performed under a microscope, a branch of the masseteric nerve is separated and sutured directly to the branch of the facial nerve responsible for smiling. The nerve fibers fuse together over several months. Once healing is complete, the corner of the patient’s mouth is pulled strongly upward when they lightly clench their teeth. The adaptability of the human brain is so great that, after a short period of physical therapy and adaptation, the patient can display a very natural and symmetrical smile merely by focusing on smiling, without even thinking about clenching their teeth.
Is It Possible to Create a New Smile in Long-Term Permanent Facial Paralysis?
If more than two years have passed since a patient experienced paralysis, the facial expression muscles in that area have completely lost their vitality and atrophied. At this stage, simply connecting the nerves does not provide any benefit. In such chronic and very delayed cases, a completely new living tissue capable of contracting must be transplanted to the face. These highly comprehensive operations represent one of the highest levels of microsurgery.
The operation process is as follows: A thin muscle from the inner thigh, known as the gracilis muscle, is selected from the body’s own muscle reserves because its removal does not cause any movement restriction or deficiency. This muscle tissue is removed from the leg as a complete system together with the artery and vein that supply it and the motor nerve that enables it to move. It is then brought to the paralyzed cheek area.
Under the surgical microscope, the blood vessels of this muscle are sutured to the vessels in the face with threads much thinner than a human hair. This ensures blood flow to the muscle and allows it to remain alive. The nerve that will trigger the muscle to contract is connected either to the chewing nerve or to a nerve bridge brought from the healthy side of the face. A long sensory nerve taken from the leg is generally tunneled beneath the skin like a bridge from the healthy side to the paralyzed side of the face. The natural smiling command from the healthy side travels across this bridge and reaches the leg muscle newly transplanted into the cheek. After months of healing, this muscle begins to contract in response to commands from the brain, and the patient, whose face has remained completely motionless for years, gains a brand-new dynamic smile composed entirely of their own tissues.
How Are Sagging Areas Caused by Facial Paralysis Corrected with Aesthetic Interventions?
Not every patient may have the general health condition required to tolerate prolonged and demanding microsurgical operations. Especially for individuals with heart disease who cannot undergo prolonged anesthesia or those in very advanced age groups, achieving balance in the face at rest becomes a priority rather than restoring dynamic muscle movement. While the healthy side of the face remains elevated and firm through muscle activity, the paralyzed side completely yields to gravity over the years and sags heavily downward. This asymmetry makes the person appear much older and more tired than they are.
Interventions used to correct this sagging and conceal the signs of facial paralysis are as follows:
- Facelift
- Midface lift
- Brow lift
- Eyelid surgery
- Lip lift
- Static suspension
In static suspension operations, healthy connective tissue taken from the body or biocompatible synthetic threads are used to mechanically pull the drooping corner of the mouth and cheek tissue upward and secure them to the healthy cheekbone. This procedure can even be performed under local anesthesia and has a rapid recovery period. By elevating the corner of the mouth, fluid leakage while eating is prevented, and the patient’s speech becomes considerably clearer.
In addition, aesthetic facelift operations are used to correct deep cheek sagging and deepened lines on the paralyzed side. Because the forehead muscle does not function, the eyebrows that have accumulated over the eye and obstructed vision are lifted with endoscopic brow lift techniques so that both eyebrows are equalized. Loose and baggy eyelid skin is removed through a procedure called blepharoplasty. These combined touches, performed with the artistic perspective of plastic surgery, eliminate the tired and asymmetrical expression on the patient’s face and create a much fresher and more balanced appearance.
How Are Involuntary Movements That Occur During Recovery from Facial Paralysis (Synkinesis) Treated?
In a very large proportion of patients who experience facial paralysis, confusion occurs while the nerve heals on its own over time, similar to the cables inside the sheath connecting to the wrong routes. This is called “abnormal regeneration” in medicine. As a result, when the patient tries to blink, the corner of the mouth twitches strongly upward, or when the patient simply tries to smile, the eye involuntarily narrows or closes completely. Persistent, painful, and highly disturbing contractions may also occur in the muscles of the neck. The contraction of a completely unrelated muscle while performing a movement is called synkinesis.
Synkinesis is a condition that isolates the patient from social life more than anything else and makes speaking, eating, or smiling in public psychologically very difficult. In addition, because the muscles on the paralyzed side of the face remain weak, the muscles on the healthy side gradually become excessively strong because they encounter no resistance and pull the entire face toward their side.
At this point, botulinum toxin, commonly known as Botox, ceases to be merely a wrinkle treatment and becomes an extremely powerful balancing treatment tool. Very low doses of toxin are injected with pinpoint accuracy under ultrasound guidance into these misdirected muscle groups that contract excessively, cause spasms, and interfere with the intended movement. This medication temporarily slows nerve-muscle transmission in that region, preventing involuntary muscle contraction and relieving painful cramps.
At the same time, toxin is also administered to strategic points in the dominant and powerful muscles on the healthy side of the face, slightly reducing their pulling force. In this way, the healthy side can no longer pull the weaker paralyzed side forcefully toward itself, and the face achieves excellent balance along the midline. Performing the injections under ultrasound guidance by visualizing the exact interior of the muscle prevents the medication from spreading to healthy muscles where it is not desired. These balancing applications, whose effects last for several months, help patients rebuild their confidence in social life and allow them to smile and speak comfortably when repeated regularly.
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.
