The phenomenon of the late recovered Bell's palsy : Treatment options to improve facial symmetry

Bell's palsy is an idiopathic neuropathy of cranial nerve VII, and the incidence ranges from 15 to 40 per 100,000. The majority of patients recover, but up to 16 percent of patients have significant sequelae. The phenomenon of the "late recovered" Bell's palsy has the following specific features and has not formerly been described: (1) tightening of the facial muscles, with a deepening nasolabial fold and reduced palpebral fissure; (2) blepharospasm; and (3) incomplete recovery of peripheral VIIth nerve branches, with ipsilateral forehead paralysis, reduced depressor anguli oris function, and poor excursion of the angle of the mouth on smiling. Nonsurgical treatment involved four monthly botulinum toxin injections. Patients had injections to paralyze the ipsilateral orbicularis oculi, contralateral forehead rhytides, and depressor anguli oris and to treat blepharospasm and muscle tightness. The effectiveness of the botulinum toxin injections on facial symmetry and patient appreciation of this were assessed by measuring brow height and teeth exposure before and 3 weeks after injection. Twenty-three patients were followed up for a mean period of 37 months. The difference in brow height and teeth exposure after injection was less than preinjection measurements, but this did not reach statistical significance. Patient self-assessments showed improvements in their appreciation of the facial symmetry, ability to go out in public, and feelings of self-worth (visual analogue scale). Surgical treatment options include ipsilateral brow lift, division of the contralateral frontal branch, contralateral tarsorrhaphy to equalize the palpebral fissures, and bilateral upper blepharoplasty. The true benefit of botulinum toxin injections was more apparent during facial animation and not when the face was static. The patients greatly appreciated the improvement in facial symmetry. Various treatment options are available to improve the quality of life for patients with late recovered Bell's palsy.