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BackTable / ENT / Article
Facial Synkinesis Treatment: Surgical & Non-Surgical Approaches
Ashton Steed • Updated Aug 1, 2025 • 37 hits
Facial synkinesis is a consequence of aberrant nerve healing after damage to the facial nerve that can result in involuntary contraction, chronic tightness, and significant pain. Patients with synkinesis experience unwanted muscle contraction with voluntary movements such as blinking, smiling, or speaking, leading to both cosmetic and functional deficits. While there is no one-size-fits-all cure for synkinesis, it is important to understand the tools we have in our toolbelt to treat these patients and improve their quality of life. Specifically, what are the management options available for facial synkinesis, and how can we tailor treatment to fit each patient’s unique clinical presentation and goals?
Fortunately, there are a variety of treatment options to improve both functional and cosmetic outcomes in facial synkinesis. Dr. Shiayin Yang, Facial Plastic and Reconstructive surgeon at Vanderbilt University Medical Center, describes both the surgical and non-surgical options available for treating these patients and maximizing their function. This article features excerpts from the BackTable ENT Podcast. You can listen to the full episode below.
The BackTable ENT Brief
• Facial synkinesis management begins with a thorough evaluation of the patient to analyze their existing function and understand which symptoms matter most to them.
• Non-surgical strategies, such as physical therapy and Botox, can help patients gain facial awareness, reduce unwanted movement, and adapt to treatment over time.
• Aesthetic periocular and brow procedures, such as brow lifts, eyelid weights, and lower lid tightening, can restore symmetry and protect eye function once facial nerve function has stabilized.
• Myectomy or selective neurectomy are additional surgical options that can improve function in carefully selected patients, such as those with debilitating disease or who seek to reduce their Botox frequency.
• Careful patient selection, photo documentation, and ongoing dialogue ensure that synkinesis management remains individualized and responsive to real-life challenges.
Table of Contents
(1) Determining Treatment Goals of Synkinesis Patients
(2) Non-Surgical Treatments for Facial Synkinesis
(3) Periocular & Brow Procedures for Facial Synkinesis
(4) Myectomy & Selective Neurectomy for Synkinesis
Determining Treatment Goals of Synkinesis Patients
Effective management of facial synkinesis symptoms begins with a detailed evaluation and discussion of the patient’s goals. A thorough physical exam and patient history help distinguish which abnormal movements are present and which symptoms actually trouble the patient. Since the severity of synkinesis and its impact on quality of life vary widely, treatment should be reserved for those experiencing significant discomfort, facial tightness, or social distress. Aligning therapeutic plans with what bothers the patient most is essential for meaningful outcomes. Ultimately, the first consultation focuses on both diagnosis and understanding each patient’s personal goals for therapy, rather than assuming all synkinesis requires intervention.
[Dr. Shiayin Yang]
Once I see a patient and I see that they have this abnormal movement, some people are not bothered, and if you're not bothered, you don't have to have treatment. There's obviously different severities in terms of the synkinesis. Examples, for maybe listeners who are not as aware, what I mean by synkinesis is when a patient tries to, let's say, close their eye, the corner of their mouth may move, or when they talk, their eye closes, but it can also be more than that. A lot of people complain of just constant tightness and pain, and pressure.
At the end of the day, it can be really hard for them. They'll get headaches, or they just have constant soreness because those muscles are just hyper-contracted. Understanding that there's a severity of disease, I think, in anything we do. There's a severity of treatments. If they're not that bothered by it, then you don't have to have treatment. You don't need to seek treatment. This is really for those patients that have a debilitating disease that's affecting their quality of life. You're really seeing some of those patients.
Initially, when I see them, it's a consultation. If the diagnosis was Bell's palsy, it's really determining does the story fit with Bell's palsy because I have seen patients come in, say they were diagnosed with Bell's palsy, then I uncover all their causes. Bell's palsy, just as a reiteration, is a diagnosis of exclusion, meaning you've ruled out everything else, and because you don't have another cause, that's what it is. It really is a clinical diagnosis. Understanding the different symptoms they present with and symptoms that they lack will really lead you towards that diagnosis.
After once I clarify what I think is their diagnosis, it's a good physical exam, seeing what parts of the face look like they're working abnormally or normally. Then, also determining what areas are affecting them. What is it that bothers them? I may see certain things that they don't notice. It's really understanding what their motivation is for treatment, and this is a resounding theme in facial paralysis. Really understanding what is that patient's goal for therapy because sometimes, maybe it's the smile that really bothers them, but I notice that they're constantly closing their eye, and they just have a lot of tightness in the midface region. It's aligning our goals, seeing what we can obtain.
That's why that first visit is usually pretty long, is just confirming the diagnosis, doing a good exam, and then understanding what are their goals for treatment.
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Non-Surgical Treatments for Facial Synkinesis
Non-surgical synkinesis therapies often begin with physical therapy to improve facial awareness, provide biofeedback, and support cortical remapping after nerve injury. Photo documentation and mirror exercises can help patients recognize subtle improvements and articulate which facial regions cause the most discomfort. Patients may also benefit from Botox injections, especially when tightness, unwanted movement, or asymmetry are persistent. Because Botox’s effects develop gradually and wear off over time, this approach requires ongoing evaluation and management of the patient, with frequent adjustments necessary along the way. However, this can be a useful option in patients who prefer to avoid surgery, as well as a diagnostic tool in preoperative planning for those who eventually want a more permanent solution.
[Dr. Shiayin Yang]
After that, I usually recommend physical therapy, starting out, it helps with biofeedback, and there are some data to suggest that there's cortical remapping after facial nerve injury. I think working with a physical therapist is pretty low risk. Actually, there's also been research to show that patients really buy back into their treatment after starting that.
Then, after that, depending just what the physical therapist says, because sometimes they want to do physical therapy prior to initiation of Botox, we then go into Botox treatment. We treat with Botox, and like I said, it's a process, just figuring out those treatment algorithms and seeing how successful it is, what benefit they're getting, what they like about it.
[Dr. Ashley Agan]
I would think it would be hard for patients to articulate the sensations and things that they feel, unless they're really looking in a mirror and doing the movements. I'm sure they learn more about their disease process as they're doing physical therapy and looking in the mirror, and being able to see what's happening. Because if you're just coming in, with the smile, I think that's obvious. I've had patients who say, "Oh, yes, we took a family picture, and my smile is off." That's always a big one. With generalized tightness, or if those muscles are just moving and pulling, I imagine that would be hard for patients to articulate or describe.
[Dr. Shiayin Yang]
Yes, that's why I think it is very helpful. It can really just help them determine what part of the face is really bothering them. Like I said, a lot of people don't want to look in the mirror, they don't want to look at what their face is. I think it also helps them. That's why another thing is photo documentation is very important, because the onset of Botox is very gradual. It usually takes about 10 days to a full two weeks to have that full onset. Then it slowly wears off.
Having those photos documented, and then oftentimes, my new patients, I'll see back after a month to see what progress we've made, and they will feel things. Then, when we review the photos together, they'll really notice, "Oh, wow, that really helped open my eye, or that improved in the way that my smile is upturning."
Periocular & Brow Procedures for Facial Synkinesis
For patients with established facial synkinesis and stable deficits, periocular and brow procedures can enhance both function and symmetry. Options include brow lifts to correct brow ptosis, blepharoplasty to remove excess upper eyelid skin, and eyelid weights or lower lid tightening procedures to protect the eye and improve closure. The tarsoconjunctival flap is another surgical technique that supports the lower eyelid, particularly in patients with significant laxity. These surgeries are typically considered about two years post-injury, once recovery plateaus, but timing can vary based on patient age and anticipated nerve regeneration. By combining aesthetic and functional procedures on both sides of the face, surgeons can restore facial balance and reduce visual asymmetry.
[Dr. Shiayin Yang]
First, before jumping into those surgeries, other surgeries that you can also consider for these patients are general aesthetic, trying to get symmetry for these patients. A lot of facial plastic procedures that you do for your cosmetic patients, you can also do for these patients, so a brow lift. A lot of patients, when they've had some type of paralysis, their brow does not regain function. You can get this big asymmetry between the brows. Easy doing an indirect brow lift, a direct brow lift, depending on the type of patient, and just giving them more symmetry for their brows.
Another area is also the upper eyelid. When you get your brow dropped, you tend to have dermatochalasis or excess upper eyelid skin that can limit your vision. Depending on their age, many people need a blepharoplasty anyways. They can really benefit from having the upper eyelid skin removed. Depending how weak their eye is, there's a lot of procedures around the eye that can be done. You can place an upper eyelid weight if they're not getting great closure. It depends on the case and the patients.
I did have one patient who was taking a while to recover, especially the eye. I did place an eyelid weight. Eventually, they got recovery back, and so I removed it. It's a relatively easy procedure to do. I typically do them in the office, about an hour. It's something nice to help them protect the eye. The other thing you can do is treat the lower eyelid. Whether it be lower eyelid tightening, where you're suspending the lower eyelid so it's a little bit shorter. Again, in our older patients, who tend to have that lower lid laxity. This is something they probably could have even benefited with before the paralysis, and the paralysis just makes it more dramatic.
Another eyelid procedure we're doing a lot of is what's called a tarsoconjunctival flap, where you actually take a bit of the conjunctiva and the tarsus from the upper eyelid, swing it down to the lower eyelid to hitch it up a little bit better, give yourself some more support. Those are some of the things you can think of for these patients in terms of if they're having periocular issues and treating them.
[Dr. Ashley Agan]
For patients who, let's say, they've gotten some asymmetry with the brow or with the eye, how long does that take to develop after their Bell's palsy or whatever the injury was? Are you usually doing those procedures months down the road, years down the road?
[Dr. Shiayin Yang]
If it's the brow and the upper eyelid, that's usually when they're more stable. Probably like two years out from their original injury. A lot of these people I see significantly far out from their initial facial paralysis. It depends. I definitely have had patients who have had an acute-type injury, and I've done a cable graft to repair their facial nerve. Then it's going to take a while for that nerve to grow back. In the meantime, if it's an elderly patient, I've gone in and done a brow, done the eyelid weight at the same time, done the lower eyelid tightening. Because, like I said, even if they develop great function back, a lot of people are still very weak in their frontalis, and they don't get great movement back. They already need a brow lift.
If they're older, they already likely have brow ptosis and really elevating that brow. I will do both sides too. I try to do everything to make them symmetric. Maybe elevating the brow on the affected side a little bit more, but also elevating it on the non-affected side. It just depends on the etiology, and what I'm expecting of their recovery.
Myectomy & Selective Neurectomy for Synkinesis
Beyond aesthetic procedures, surgical synkinesis management can also directly target overactive muscles or misdirected nerves through myectomy and/or selective neurectomy. Myectomy involves cutting out a section of hypercontracted muscles, like the depressor anguli oris, to reduce downward pull and improve smile symmetry. Selective neurectomy is another surgical alternative where aberrant facial nerve branches that are responsible for unwanted movements are surgically ligated. However, this approach is less predictable and should be reserved for patients with severely debilitating disease who may be wanting to reduce their reliance on Botox. While both of these surgeries don’t necessarily eliminate the need for Botox, they may reduce the frequency or dosing required and relieve chronic tightness or pain in carefully selected, motivated patients.
[Dr. Shiayin Yang]
Then the next type of procedures are really trying to work at improving the synkinesis or the abnormal movement. There's two different types of surgeries that can be done. One is a myectomy, where you're essentially targeting the abnormal end organ, which is the muscle. The other is neurectomy, where you're targeting the nerve that is inappropriately or rerouted the wrong way, getting innervation to the muscle and causing abnormal movement or unwanted abnormal movement.
These are the two areas. They've been around for a while, but there's been a lot more traction in terms of the neuroectomies recently and the procedures that are being done. This is the newer surgery that's gained a lot more popularity and is being done a lot more, and just still trying to figure out what is the best possible outcome. I guess starting with myectomies, what you're trying to do is you're trying to target muscles that may be in that more hyperkinesis or hypercontracted state, giving you unwanted movement.
The popular areas targeting is the depressor anguli or DAO, most commonly. That will give patients this downward-pulled smile. You'll see that a corner of the mouth is pulled down, and if you treat them with Botox targeting their DAO, or you could even do a test in the office with lidocaine numbing that area, seeing if it gives elevation of their oral commissure. That can be a good indicator that cutting that muscle would be beneficial and would help them give the upward movement of their smile. It's something that's easy. It can be done. You can do it through the mouth in the office, and you're literally just cutting out a large swath of that muscle.
[Dr. Ashley Agan]
When you say large, like a centimeter?
[Dr. Shiayin Yang]
Yes, like a centimeter, two centimeters, so that the muscle is completely disconnected. That's probably the most popular one. The other one is or other areas that can be targeted is the platysma. Patients who have just a lot of platysmal banding, a lot of neck tightness, that's also an easy area where you can target that muscle. Sometimes the depressor, the DLI, can also be targeted, depending if they're getting a lot of downward pull. This one's I think a little harder to address than the DAO, but that can also be addressed just to help improve the appearance and their smile.
These can also be done in combination with neuroectomies. Doing a selective neuroectomy. With that, it's usually you're deciding on your patients in terms of your patients who have been doing really well with Botox, but maybe they have a pretty severe synkinesis. They either have a lot of tightness or a lot of unwanted movement. You've treated them with a lot of Botox. They've gotten good results from the Botox.
You can also do little lidocaine blocks to see in the general area. You can target their buccal branch if you do an injection mid-cheek or around where the marginal mandibular branch comes, so around the facial notch. That can give them evidence of what cutting those nerves in those areas might look like and help improve with their appearance. Essentially, a selective neurectomy, it's a facelift-type incision. You're exposing all the nerves within the face. Then you're actually stimulating the nerves in troughs, seeing which ones are giving you unwanted movement. It's a balance of finding ones that maybe cause this downward pull of the lip or significantly more the depressor type movement of the mouth and the smile, and clipping those nerves to essentially weaken that forceful effect that they have.
[Dr. Ashley Agan]
That sounds like a much harder surgery, tracing out all those little tiny nerves.
[Dr. Shiayin Yang]
It's a much more involved surgery, harder surgery. I think a little harder to predict as well what exactly their outcomes will be. A lot of these patients still need Botox or are still going to have Botox. It's not going to restore them back to what they were before. I think it's really having a good understanding with the patient, but even if you can decrease the amount of Botox, just having that constant relief of the pressure and neck pain or mid-facial pain, a lot of patients find it worth it.
[Dr. Ashley Agan]
You mentioned with the myectomy, the common targets are for patients who are having a lot of downward pull around the mouth or platysmal banding. With the selective neuroectomy, are there common movements that that works best for?
[Dr. Shiayin Yang]
I think that is evolving in terms of what people are treating that for. The common ones for myself are tightness of the neck, downward pull of the mouth, very drastic, or my patients with more severe facial paralysis who have done really well with Botox. More and more people or I'd say some of my colleagues in the country, are now treating areas around the eye. The concern is, could you potentially risk these patients not being able to close their eye really well? There's still a lot that needs to be learned about how long is this effective, how long does it work? Tessa Hadlock, a while ago, actually published on patients who she did neuroectomies around the eye and found that over time these patients still needed increasing amounts of Botox. Questioning, how well does this actually work? The same argument can be done for the nerves around the face or the rest of the face. That's why I think it just needs a little bit more time to really understand how well these patients are doing after surgery and also understanding, what do you do with the clipped nerve ends.
I think that is an area that is further being explored. Not just cutting the nerve and clipping both ends, but also taking out a chunk of the nerve. About a centimeter of the nerve clipping both ends. Then some people are dunking the nerves into the masseter muscle, giving it something else to innervate. There's been some data within plastic surgery where they actually, in other peripheral nerves, wrap the nerves in muscle. You could take a little bit of the SCM and wrap it around the cut nerve end.
I think it's an exciting field and it still has a lot more that has to be understood and better developed before it becomes anywhere near the more regimented and predictable type surgery.
[Dr. Ashley Agan]
Interesting. For now, that selective neurectomy, it's not most of your patients, I would assume. That's kind of a select group of patients that maybe have a really severe synkinesis that they're just wanting that next step, but also it's not predictable, and there's no guarantees. I'm sure there's a lot of upfront counseling.
[Dr. Shiayin Yang]
Correct. It's, at least for my practice, it's for those patients who have very severe disease and extremely debilitating disease and trying to maybe lessen how much Botox they're getting and give them some type of permanent relief. It's really for my patients who have them and who are really motivated and saying they want to do something else. They realize that and may not be able to exactly predict how it is going to be after surgery, but they want to do something more than just Botox.
[Dr. Ashley Agan]
All right. For your outcomes for that, for the selective neurectomy, percent-wise, how many people have improvement, or how do you grade it? Some improvement, a lot of improvement, zero improvement? How do you assess your outcomes after that?
[Dr. Shiayin Yang]
Really it's just if we can decrease the amount of Botox and if they subjectively have improvement. Because a lot of this disease, outside from the way that I evaluate them, is also, like we said, the feeling of things and the improvement in the tightness that they're having or the feeling that it's more they're telling me that they have relief and they've noticed improvement in the way they eat or if they've noticed in their smile.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2024, August 27). Ep. 188 – Surgical Management of Synkinesis & Static Procedures for Flaccid Facial Palsy [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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