Facial Paralysis Exercises: How to Perform Them Safely and Effectively

Facial paralysis exercises should be performed while sitting upright in front of a well-lit mirror, without tiring the muscles, in short periods three times a day, very slowly and absolutely without using excessive force. The fundamental principle here is not to give the facial muscles brute strength, but to delicately reprogram the communication between the brain and the face through mental focus. Areas that resist movement should be guided with very light support from the fingertips, and the healthy side of the face must be prevented from contracting excessively and creating asymmetry. For proper nerve-muscle recovery, exercise should be stopped as soon as fatigue is felt, and all facial expressions should be practiced in an isolated and controlled rhythm in order to preserve aesthetic symmetry.

What Is Facial Paralysis and Why Does It Occur?

Facial paralysis, medically known as peripheral facial paralysis, is a highly complex health problem that occurs when the facial nerve, the seventh cranial nerve, is damaged at any point during its course from the brain to the facial muscles. You can think of this nerve as the main electrical wiring system of an extremely advanced and complex smart home. The nerve travels through a very narrow, bone-built tunnel located in the temporal bone inside the skull, called the fallopian canal, and then branches out toward the face.

This tunnel is only wide enough to accommodate the dimensions of the nerve. When the nerve tissue begins to swell due to any infection, inflammation, or trauma, the surrounding bone cannot expand, causing the nerve to become compressed within its own tunnel. This compression damages the outer sheath of the nerve and the communication fibers within it, disrupts blood flow, and ultimately prevents the movement commands sent by the brain from reaching the facial muscles. As a result, sudden and unilateral loss of movement develops in all facial expression muscles on one half of the face.

The main factors that can cause facial paralysis are as follows:

• Viruses
• Exposure to cold
• Physical trauma
• Middle ear infections
• Tumors
• Surgical complications

Which Physical Symptoms Are Observed in Patients Who Have Experienced Facial Paralysis?

When the facial nerve is damaged, a simultaneous loss of function occurs in all muscle groups controlled by the nerve, and a very characteristic asymmetry develops on the affected half of the face. Waking up one morning and looking in the mirror to see one side of the face completely motionless and drooping downward under the effect of gravity is a deeply distressing experience for patients. The patient cannot wrinkle the forehead or raise the eyebrow.

One of the most critical and dangerous symptoms is the inability of the upper eyelid to close completely due to dysfunction of the circular muscle around the eye. In this condition, medically called lagophthalmos, when the person tries to close the eye, the eyelid does not descend, but the eyeball rolls upward as a natural reflex. In the middle and lower facial region, the natural crease extending from the side of the nose to the corner of the mouth disappears completely, and the corner of the mouth droops downward, disrupting the structure of the mouth. This anatomical drooping not only makes it difficult for the person to pronounce certain sounds while speaking, but also causes liquids to spill involuntarily from the corner of the mouth while drinking water or tea. In addition, because this nerve is responsible not only for movement but also for certain fine sensations, additional symptoms that reduce the patients’ quality of life may also be added to the condition.

Common clinical symptoms include:

• Inability to close the eye
• Asymmetrical facial contour
• Lip drooping
• Loss of taste
• Excessive sensitivity to sounds
• Saliva leakage
• Excessive tearing

What Are the Main Differences Between Central and Peripheral Facial Paralysis?

Before correctly determining the treatment strategy and the exercise protocols to be applied later, distinguishing where the source of the facial paralysis originates is an extremely vital step. Facial paralysis can essentially result from two different causes: either directly from a center in the brain (central) or from the nerve pathway after it leaves the brain (peripheral).

In peripheral facial paralysis, the forehead region on the damaged side of the face is completely motionless; the patient cannot wrinkle the forehead or raise the eyebrow in any way. This is because the nerve has been blocked at a single point together with all its branches. However, if the paralysis is due to a brain-centered central cause such as cerebral hemorrhage, stroke, or cerebral vascular occlusion, the condition is completely different. Thanks to an extraordinary defense mechanism in human anatomy, the forehead muscles receive crossed nerve connections from both cerebral hemispheres. Therefore, in central facial paralysis, the movement of the forehead muscles is largely preserved, and the patient can wrinkle the forehead even on the paralyzed side. Eyelid functions are also generally preserved in central involvement. This distinction is made meticulously by specialists in order to rule out the presence of a life-threatening condition and select the correct reconstructive approach.

What Is the Plastic Surgery Approach in the Treatment of Facial Paralysis?

Plastic, reconstructive, and aesthetic surgery aims not only to create cosmetic symmetry in the treatment of facial paralysis but also to permanently restore lost vital functions. Facial expressions are the most fundamental element of human communication, and the loss of these expressions may cause the person to become isolated from society. Therefore, the treatment approach is multidimensional.

After medication treatments applied in the early period, if the nerve does not heal on its own, highly detailed dynamic and static surgical procedures such as nerve repairs using microsurgical methods, muscle transfers from distant regions, and facial suspension are performed. However, the surgical sutures placed on the operating table are only the beginning of the process. In order for surgery to turn into true success, namely a functional and natural smile, nonsurgical options such as neurotoxin injections and specially designed clinical exercise programs are introduced during the postoperative period. The entirety of these treatments enables the tissues to become revitalized and move correctly.

What Does Botox Application Do in the Treatment of Facial Paralysis?

The muscles in our face work in perfect balance against each other like a seesaw mechanism. The right side pulls to the right and the left side pulls to the left with equal force. When one half of the face is paralyzed, this mechanical resistance suddenly disappears. In this situation, because the muscles on the healthy side of the face encounter no opposing braking force, they begin to overwork, meaning they become hyperactive. The healthy side mercilessly pulls the paralyzed side toward itself, and severe distortion and asymmetry appear on the face even when the patient is completely at rest.

In modern medicine, botulinum toxin, commonly known as Botox, is frequently used to balance this asymmetry and restore nerve-muscle harmony. Botox prevents excessive contraction of the muscle by temporarily interrupting the chemical communication from the nerve to the muscle cell. When applied to the hyperactive muscles on the healthy side, it immediately re-establishes facial symmetry and prevents the healthy side from pulling on the paralyzed side. It is also used to manage uncontrolled muscle spasms that may develop over time on the paralyzed side. Performing the procedure under the guidance of ultrasound devices increases the safety of the treatment by enabling the medication to be injected into the target muscle with millimetric precision.

The main areas where Botox injections are performed are as follows:

• Forehead on the healthy side
• Area between the eyebrows on the healthy side
• Crow’s feet on the healthy side
• Corner of the mouth on the healthy side
• Neck area

What Should Be Done to Protect Eye Health After Facial Paralysis?

In cases where dynamic surgical methods cannot be applied in facial paralysis or a long recovery period is expected, protecting eye health is by far the highest priority. The inability of the eyelid to close completely causes the corneal layer to dry out due to continuous exposure to air, dust, and wind. This condition can rapidly progress to irritation, followed by very painful inflammation known as exposure keratitis, and, if left untreated, may lead to perforation of the cornea and permanent blindness.

Protective procedures are applied to prevent this vital risk. The first step is to keep the eye moist throughout the day with artificial tear drops and to mechanically close the eyelid at night with special medical tapes. As a more permanent solution, a gold implant is placed in the upper eyelid. Because gold is one of the heavy metals most compatible with body tissues, it does not cause a reaction. This small gold plate placed inside the eyelid uses the force of gravity entirely, allowing the upper eyelid to descend passively when the patient wants to close the eye. To prevent outward drooping of the lower eyelid, small supportive surgeries are performed in which the corners of the eyelid are tightened.

Which Microsurgical Operations Are Performed in Cases of Permanent Facial Paralysis?

If a long period such as six months to one year has passed since the paralysis, if wasting (atrophy) has begun in the facial expression muscles, or if the nerve was completely severed and irreversibly damaged at the time of the initial injury, permanent facial paralysis is considered to be present. At this advanced stage, expectant treatment is abandoned, and highly sophisticated dynamic reanimation surgery methods are used in order to restore a voluntary, natural smile to the patient.

If the facial muscles have not yet wasted away but nerve conduction has been completely interrupted, nerve grafting procedures are performed in which nerves taken from other parts of the body are used as bridges. One of the most remarkable and effective methods is cross-face nerve grafting. In this technique, the surgeon deliberately sacrifices one or several small terminal branches responsible for smiling from the seventh nerve on the healthy side of the face. Then, a long sensory nerve taken from the patient’s leg is extended from the healthy side of the face to the paralyzed side by creating tunnels under the skin. Thanks to this nerve bridge, when the patient wants to smile, the signal sent by the brain reaches the healthy side and then passes to the paralyzed side through this new bridge. The progression of the nerve through this long bridge to reach the opposite side is a very slow biological process and advances only one millimeter per day.

The tissues used in the treatment of permanent paralysis are as follows:

• Leg sensory nerve
• Neck nerve
• Chewing nerve
• Tongue nerve

How Is Muscle Transfer (Free Flap) Performed in Facial Paralysis Operations?

In cases of facial paralysis lasting for years, because no electrical signal reaches the muscles, the facial expression muscles become completely thin, waste away, and disappear. In these chronic cases, merely bringing a nerve bridge from the healthy side is of no benefit because no healthy muscle tissue remains to receive that signal and contract. At this point, the highest-level surgical technique that comes into play is free microneurovascular muscle transfer.

In this procedure, a portion of muscle from the inner part of the patient’s thigh, usually the gracilis muscle, is completely separated from the body together with its supplying artery, vein, and motor nerve and made free. This muscle tissue is then placed in the facial region between the corner of the mouth and the temple. The extremely thin vessels of the muscle are sutured to the vessels in the neck or face under a surgical microscope using threads much thinner than a strand of hair, thereby ensuring the blood supply and survival of the muscle. The nerve of this newly transferred muscle is then connected either to the nerve bridge previously brought from the opposite side or to the chewing nerve on the same side.

In addition, in some cases, the temporalis muscle located in the patient’s temple region, which normally functions in chewing, is partially detached from its position and extended toward the corner of the mouth to enable facial movement. While performing this procedure, surgeons deliberately suture the face in an excessively upward-lifted position. This is called overcorrection. Although the face initially appears very asymmetrical and excessively tight, it settles into an ideal and aesthetically symmetrical level within a few months under the effect of gravity and tissue stretching.

How Do the Physical Therapy Stages Progress After Facial Paralysis Operations?

The success achieved after a dynamic facial paralysis operation depends on how well the patient complies with the postoperative physical therapy and rehabilitation process. The nerves and muscles may have been sutured together on the operating table, but the brain does not yet know that a muscle taken from the leg is now a “smile muscle.” This adaptation is a gradual process that must be managed very well.

The first few days after the operation focus entirely on protecting the surgical incisions and reducing the edema that has developed. During this very early period, all movements that may strain the muscle are avoided. Only very gentle massages that create a sensation of touch are applied. After the first weeks have passed, tissue massages are started to increase the flexibility of the scars, along with active-assisted movements in which the patient looks in the mirror and gradually tries to feel the muscle. Once the muscle has attached to its new position, special coordination training is initiated so that the brain can perceive this new muscle. The goal of this marathon, which will last for months, is to build an entirely new nerve-muscle connection highway.

The main phases of the physical therapy process are as follows:

Edema control

Scar massage

Active-assisted movement

Coordination training

Resisted exercises

What Is the Relationship Between Facial Paralysis Exercises and Electrical Current (Electrostimulation)?

In modern physical therapy, electrical stimulation, or electrostimulation devices, are frequently used to activate paralyzed muscles in other parts of the body. However, when it comes to facial paralysis and the delicate facial expression muscles of the face, the use of these devices is rejected in the medical world with very clear boundaries. Applying external electrical current to the facial muscles of a patient who has experienced facial paralysis and whose nerves are in the process of healing and sprouting again is a major mistake. Electrical current causes all the muscles to contract very strongly at the same time, leading the newly growing nerve fibers to become confused and connect to the wrong muscles. This results in permanent contractions in the face.

However, as in every field of medicine, there is also a very specific exception here. If the patient has undergone a special myoplasty operation in which their own temporalis muscle is moved downward, the situation changes. The temporalis muscle is not a natural facial expression muscle; it is a strong skeletal and chewing muscle. Therefore, its stimulation threshold is different. Approximately one month after this special operation, when the sutures have completely healed, cutaneous electrical stimulation directed only at that muscle may be applied under physician supervision and at very specific frequencies. This procedure increases the contraction speed of the temporalis muscle, helping the patient smile more symmetrically and quickly with the new muscle.

The areas where electrical stimulation is prohibited are as follows:

• Muscles around the eyes
• Forehead region
• Around the lips
• Neck region

How Should Facial Paralysis Exercises Be Performed at Home and How Should the Environment Be Prepared?

When patients begin a clinical exercise program at home with specialist approval, the physical preparation of the environment directly determines the quality of the exercise. The fundamental philosophy of facial paralysis exercises is never to tire the muscles until they sweat or strain them as if lifting weights. The main goal is to retrain the brain. Therefore, complete concentration is essential.

The patient must perform the exercises in a very well-lit environment where even the slightest shadows on the face can be seen. The patient should sit directly in front of a large and clean mirror, lower the shoulders, and sit in an upright and comfortable posture. The purpose of the mirror is not merely for the patient to look at their own face, but for the brain to receive visual feedback, perceive the asymmetry between the healthy side and the paralyzed side, and instantly calibrate the intensity of the contraction accordingly. During exercise, external sounds, the television, or the phone should not be allowed to distract attention. The patient should focus only on the millimetric muscle fiber they want to move and perform the movement extremely slowly, consciously, and almost by visualizing it mentally.

The requirements for the exercise environment are as follows:

• Large mirror
• White light
• Chair with an upright backrest
• Quiet room

How Is the Forehead Region Exercised Within the Scope of Facial Paralysis Exercises?

The upper part of the face, especially the forehead and eyebrow area, is a very important region where the most basic human emotions such as surprise, fear, excitement, and attention are reflected. A special rhythm should be followed to reactivate the forehead muscle, the m. frontalis. While sitting in front of the mirror, the patient first relaxes by taking a deep breath. Then, the patient tries to raise both eyebrows upward equally and slowly. While performing this movement, also known as the expression of surprise, mental effort is more important than physical effort.

If the eyebrow on the paralyzed side does not move at all or lags far behind compared with the healthy side, the patient should place the index finger of that side horizontally just below the eyebrow. Without straining the muscle, the patient should gently support the eyebrow upward with the soft touch of the fingertip and bring it to the same level as the healthy side. The patient should hold this position for approximately three seconds and then slowly lower it again with finger support. Next, the movement of frowning the two eyebrows toward the midline and the bridge of the nose, which is referred to as an expression of anger, should be performed. The key point in all these movements is to prevent the healthy side from working excessively and making the face even more distorted. If necessary, the healthy side should also be held with a finger to restrain the movement.

How Should Eyelid Movements Be During Facial Paralysis Exercises?

The muscle structure around the eye has a much thinner, more delicate, and sensitive sphincter structure than the other regions of the face. The most important function of this muscle is to clean the eye like a windshield wiper and protect it from external factors. The greatest danger while performing eye exercises is that the patient may strain excessively in an effort to close the eye and mix all the facial muscles together.

At the beginning of the exercise, the patient keeps the head upright and looks downward using only the pupils. Then, the patient tries to lower the upper eyelid extremely slowly and gently. If the eyelid resists closing, the patient uses the back of the index finger of one hand to provide a feather-light mechanical downward support to the upper eyelid. Pressure must never be applied to the eye; only the skin should be helped to slide downward. At the same time, the eyebrow on the paralyzed side is gently stretched upward with the fingers of the other hand, creating an opposing resistance point for the muscle. In the second stage, an attempt is made to gently narrow both eyes at the same time in a controlled manner without squeezing too hard. During this process, care should be taken to keep the cheek and lip area completely motionless and relaxed.

What Are the Nose and Breathing Techniques for Facial Paralysis Exercises?

Specific exercises for the nasal muscles are performed to activate the dynamics of the midface region and synchronize breathing habits with facial movements. The muscles that widen and narrow the nostrils are directly connected to the act of inhaling and exhaling.

While taking a very deep and slow breath through the nose in front of the mirror, the patient simultaneously focuses on widening, or opening, the nostrils outward as much as possible. The urge to take a deep breath naturally activates the nostril muscles. If the nostril on the paralyzed side does not open, light outward and upward support may be provided from the outside of the nostril with the fingertip. While exhaling, the nostrils are allowed to slowly return to their previous position. This synchronized breathing exercise makes a major contribution to reprogramming the brain’s automatic breathing reflexes and the voluntary movements of the facial muscles on the same network.

How Are Mouth and Smiling Functions Improved With Facial Paralysis Exercises?

The circular muscle around the mouth and the elevator muscles extending from the cheeks to the corners of the lips are the main architects of both chewing and speech functions and of the smile, which is our most powerful tool in human relationships. Letter and syllable exercises in which the lips take different shapes are highly effective for retraining this region.

In front of the mirror, the patient first tries to create a symmetrical smile by slowly moving the corners of the lips outward and upward. When the paralyzed side lags behind, the patient holds that corner of the lip with the index finger, brings it to the same level as the healthy side, and tries to hold the muscle at that point with their own strength. Then, vowel practice is performed by pursing the lips forward. In particular, sounds in which the oral cavity and lip shape change dramatically are repeated consecutively, loudly, and with exaggerated facial expressions. In addition, the exercise of inflating the cheeks with air and holding that air inside the mouth without allowing it to leak out rapidly increases the region’s ability to hold water and chew.

The sounds that should be repeated during the exercises are as follows:

• A sound
• O sound
• U sound
• E sound
• I sound

How Is Synkinesis (Unwanted Associated Movement) Prevented During Recovery From Facial Paralysis?

One of the most troublesome problems encountered by patients with facial paralysis during the recovery process is involuntary contractions medically known as synkinesis. When the nerve sheath is damaged, the thousands of fine electrical wires, or nerve fibers, inside it begin to regrow and extend toward the muscles. However, during this growth, some fibers lose their way and connect to the wrong muscles. For example, a nerve fiber that should go to the corner of the mouth and enable smiling may accidentally deviate upward and connect to the eye-closing muscle. As a result, every time the patient smiles, the eye on that side closes tightly and completely involuntarily. Or, when the patient blinks, the neck muscles contract.

The greatest trigger for this electrical leakage and incorrect wiring is the patient exerting excessive effort to move the paralyzed muscle during exercise and using brute force by contracting the entire face, neck, and jaw. When the brain sends excessive signals to that region, the nerve fibers spread out more and attach to incorrect locations. The only and most certain way to prevent synkinesis is to perform the exercises extremely slowly, in isolation, and with low effort. When working the lips, the area around the eyes must be left completely relaxed, and when working the forehead, the jaw must not be clenched. The point of focus is not to activate any unwanted additional muscle.

The main mistakes that trigger synkinesis are as follows:

• Squeezing the face excessively
• Moving rapidly
• Tensing the neck muscles
• Locking the jaw

What Are the Common Mistakes Made During Facial Paralysis Exercises?

During clinical exercise practices performed at home, some basic mistakes made by patients due to the desire to recover as soon as possible may set the recovery process back by months. The most common mistake is the misconception that “the more I exercise, the faster I will recover.” Instead of performing the exercises for hours once a day and completely exhausting the muscles, they should be divided into short sessions in the morning, at noon, and in the evening.

The second major mistake is continuing to force the muscles even when the slightest fatigue, twitching, or pain is felt in the muscles or face. When the facial muscles become tired, they completely lose their ability to contract, and the brain then activates the healthy side more, further aggravating the asymmetry. In addition, neglecting eye protection while trying to keep the eye open for a long time during exercise is also a serious problem. The use of artificial tear drops should not be neglected between exercises and throughout the day.

Frequently Asked Questions

Prof. Dr. Serdar Nasır

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.