Facial Palsy: Causes, Symptoms and Treatment

Woman assessing one side of her face during a facial palsy consultation at Centre for Surgery London — Most facial palsy recovers substantially. What matters most is getting the right care in the first three days — and knowing what to do if recovery stalls.

In this guide13 sections

Is facial palsy a stroke? How to tell the difference
What is facial palsy?
What are the symptoms of facial palsy?
Facial palsy grading and classification
What causes facial palsy?
What is the treatment for facial palsy?
How to protect the eye with facial palsy
Can you fully recover from facial paralysis?
Facial palsy treatment in children
Facial palsy surgery: what a plastic surgeon can treat
What to expect at a consultation
Frequently asked questions about facial palsy
Why choose Centre for Surgery

Facial palsy is weakness or paralysis of the muscles on one side of the face, caused by a problem with the facial nerve. Bell’s palsy accounts for around 80% of cases, and most people recover substantially. Treatment depends entirely on the cause and on how long the weakness has been present.

Two things matter more than anything else on this page. First, sudden facial weakness can be a stroke, and stroke is a 999 emergency — the section below explains how the two differ. Second, if it is Bell’s palsy, steroid treatment works best when started within 72 hours, so this is a same-day GP or NHS 111 call, not something to watch for a week.

This guide covers what causes facial palsy, how it is treated at each stage, how to protect the eye, what recovery realistically looks like, and — where weakness or asymmetry persists after recovery has plateaued — what reconstructive and surgical options exist.

Is facial palsy a stroke? How to tell the difference

Diagram showing forehead sparing in Bell's palsy versus forehead weakness in stroke, and when to call 999 — The forehead is the single most useful sign. In Bell’s palsy the forehead usually still moves. In stroke it often does not.

This is the first question to settle, and it is the reason this section comes before everything else.

Call 999 immediately if facial weakness comes on suddenly and any of the following are present:

The forehead is also weak — you cannot raise the eyebrow or wrinkle the forehead on the affected side
Arm weakness — one arm drifts downward when both are raised
Speech problems — slurred, garbled, or difficulty finding words
Any weakness elsewhere in the body, or sudden confusion, severe headache or visual loss

That is the NHS FAST test — Face, Arms, Speech, Time to call 999.

Why the forehead matters

The muscles of the forehead receive nerve supply from both sides of the brain. The muscles of the lower face receive supply from one side only.

The practical consequence is important. A stroke affects the nerve pathway above the level where those signals divide, so the forehead is usually weak along with the rest of that side — but sometimes it is partly spared by the double supply, which is why the other FAST signs matter too. Bell’s palsy affects the facial nerve itself, after that division, so the whole side including the forehead is weak.

Clinicians call this forehead sparing, and it is the basis of the UMN vs LMN facial nerve palsy distinction taught in medical schools. An upper motor neurone (UMN) facial nerve palsy — typically a stroke — often shows forehead sparing, because the double supply keeps some movement. A lower motor neurone (LMN) facial nerve palsy — Bell’s palsy and most other causes of facial paralysis — affects the whole side, forehead included.

Forehead sparing is genuinely useful, but it is not perfect, and it is not a test to rely on alone at home.

If you are unsure, treat it as a stroke and call 999. Arriving at hospital and being told it is Bell’s palsy is a good outcome. The reverse is not.

Is Bell’s palsy a mini stroke?

No. A mini stroke, or transient ischaemic attack (TIA), is caused by a temporary interruption to the blood supply to part of the brain. Bell’s palsy is inflammation affecting the facial nerve itself. They are entirely different conditions with different causes and different urgency.

The confusion is understandable, because both can produce a one-sided facial droop that appears quickly. That is exactly why the distinction should be made by a clinician rather than at home.

What is facial palsy?

Facial palsy is weakness or complete paralysis of the muscles supplied by the facial nerve — the seventh cranial nerve. There is one on each side of the head, and each supplies the muscles of expression on its own side.

The nerve does more than move muscles. It also carries taste from the front of the tongue, controls tear and saliva production, and supplies a small muscle in the middle ear that dampens loud sound. This is why facial palsy is rarely just a movement problem, and why people often report a metallic or altered taste, a dry or watering eye, and sounds seeming uncomfortably loud on the affected side.

Only one side is affected in most cases, so the visible result is facial asymmetry — though facial palsy is only one of many causes of an asymmetrical face, and by no means the most common.

The facial nerve and its branches

Anatomy diagram of the facial nerve and its five branches — temporal, zygomatic, buccal, marginal mandibular and cervical — The facial nerve emerges in front of the ear and fans into five branches. Which branches are affected determines which parts of the face are weak.

After leaving the skull just in front of the ear, the nerve divides into five main branches:

Temporal — forehead and eyebrow
Zygomatic — eyelid closure
Buccal — cheek, upper lip and nostril
Marginal mandibular — lower lip
Cervical — the platysma muscle in the neck

Facial palsy can affect all branches or only some. Isolated marginal mandibular weakness, for example, produces an uneven smile with a normal eye and forehead. Understanding which branches are involved is central to planning any later treatment.

What are the symptoms of facial palsy?

Symptoms usually affect one side and may include:

Drooping of the mouth corner, with dribbling and difficulty keeping food or drink in, and an uneven smile or asymmetrical lips
Inability to close the eye fully — known as lagophthalmos. This is distinct from the droopy eyelids or ptosis caused by ageing, though the two can look similar at a glance. Lagophthalmos can also follow eyelid surgery where too much skin was removed, as our guide to blepharoplasty abroad explains
A drooped eyebrow, sometimes obstructing the upper field of vision — see our guide to how to fix a drooping eyebrow
Loss of the nasolabial fold — the crease running from nose to mouth flattens on that side
A dry or watering eye, and eye irritation or grittiness
Altered taste at the front of the tongue
Sounds seeming abnormally loud on the affected side
Pain around or behind the ear, often preceding the weakness by a day or two
Difficulty with speech, particularly sounds needing lip closure — b, p, m

Bell’s palsy typically develops over hours to a couple of days and is often at its worst within 72 hours. Weakness that develops gradually over weeks or months is different and warrants investigation for another cause.

Facial palsy grading and classification

Clinicians grade facial palsy to track recovery objectively rather than by impression. The most widely used facial nerve palsy grading system is the House-Brackmann scale, which runs from I to VI:

Grade I — normal function throughout
Grade II — slight weakness noticeable only on close inspection; complete eye closure with minimal effort
Grade III — obvious but not disfiguring difference; complete eye closure with effort; slight synkinesis may be present
Grade IV — obvious weakness or disfiguring asymmetry; incomplete eye closure
Grade V — only barely perceptible motion; incomplete eye closure
Grade VI — total paralysis, no movement at all

The step between grade III and grade IV is the one that matters most day to day, because it is where eye closure stops being complete — and that is what determines how intensively the eye needs protecting.

Other classification systems exist, including the Sunnybrook and eFACE scales, which score regions of the face separately and are more sensitive to partial recovery and synkinesis. Any of them is more useful than “a bit better than last month”, which is why a graded assessment forms part of any proper facial palsy review.

What causes facial palsy?

Causes divide into those present from birth and those acquired later.

What triggers Bell’s palsy?

Bell’s palsy is the single most common cause, accounting for roughly 80% of facial palsy. It is diagnosed when no other cause is found. The nerve becomes inflamed and swells within the narrow bony canal it passes through, and that compression interrupts its function.

Why this happens is not fully established. Reactivation of a dormant virus — most often herpes simplex — is the leading explanation. Recognised associations include recent viral illness, pregnancy (particularly the third trimester and the first week after delivery), diabetes, high blood pressure and obesity. Many people have no identifiable trigger at all, which can be frustrating but does not change the treatment.

Other acquired causes

Stroke — as above, an emergency
Ramsay Hunt syndrome — shingles affecting the facial nerve, typically with a painful blistering rash in or around the ear. It carries a poorer outlook than Bell’s palsy and needs prompt antiviral treatment
Lyme disease — a recognised cause in the UK, especially after a tick bite, and one of the more common causes of facial palsy affecting both sides
Middle ear infection or cholesteatoma
Tumours — including acoustic neuroma and parotid gland tumours. A slowly progressive weakness, or a lump in front of the ear, needs investigation
Trauma — skull base fracture, facial injury, or injury during surgery in the region
Neurological conditions such as multiple sclerosis or Guillain-Barré syndrome

Congenital facial palsy

Some children are born with facial palsy. It may be isolated, caused by incomplete development of the nerve or muscle, or part of a syndrome such as Moebius syndrome or hemifacial microsomia. Asymmetric crying facies — where one side of the mouth pulls down when a baby cries — is a limited form that often becomes less noticeable with time.

What is the treatment for facial palsy?

Treatment depends on the cause and on timing. The distinction between the acute phase and the long-term phase matters, because the right treatment in one is the wrong treatment in the other.

The first 72 hours

This phase is managed by your GP, NHS 111 or an emergency department — not by a cosmetic clinic.

For Bell’s palsy, a course of oral corticosteroids is the standard facial paralysis treatment medicine. The usual steroid dose is prednisolone over around ten days, prescribed by your GP against national guidance — the exact facial palsy treatment dose depends on your weight, your other medications and any conditions such as diabetes, which is why it is prescribed rather than bought. The evidence for benefit is strongest when treatment starts within 72 hours of symptoms beginning, which is why speed matters far more than choice of provider.

The 72-hour figure is not a rule of thumb. It comes from the Scottish Bell’s Palsy Study, a double-blind randomised trial of 551 patients published in the New England Journal of Medicine, in which everyone was recruited within 72 hours of symptoms starting. At three months, 83.0% of those given prednisolone had recovered facial function, against 63.6% of those who did not receive it. By nine months the figures were 94.4% and 81.6% (Sullivan et al., 2007 — read the abstract on PubMed, doi:10.1056/NEJMoa072006).

A Cochrane systematic review pooling seven trials and 895 participants reached the same conclusion: 17% of those treated with corticosteroids had incomplete recovery at six months or more, against 28% of controls. Roughly ten people need treating to prevent one incomplete recovery, and steroids also significantly reduced synkinesis — the unwanted linked movement described below (Madhok et al., 2016 — read it on PubMed, doi:10.1002/14651858.CD001942.pub5).

Antivirals are a more nuanced picture. A Cochrane review of 14 trials and 2,488 participants found that adding an antiviral to steroids made little or no difference to whether people recovered — but did reduce the longer-term sequelae of synkinesis and crocodile tears (Gagyor et al., 2019 — read it on PubMed, doi:10.1002/14651858.CD001869.pub9). In practice antivirals are added in selected cases, particularly where Ramsay Hunt syndrome is suspected. Antibiotics are used where Lyme disease is the cause. Where the cause is a stroke, treatment is entirely different and time-critical.

Alongside medication, eye protection begins immediately — see the section below.

Facial palsy treatment: physiotherapy and exercises

Specialist facial therapy — sometimes called facial neuromuscular retraining — is delivered by physiotherapists or speech and language therapists with specific training in facial palsy. It is not the same as generic facial exercise.

The aim is to retrain coordinated movement rather than to build strength. That distinction matters: vigorous, forceful exercise of a recovering facial nerve is generally discouraged, because it can encourage synkinesis — unwanted linked movement, such as the eye closing when you smile — which is difficult to undo once established.

If you are looking for facial palsy exercises or facial palsy treatment at home, the safest approach is to have them prescribed by a facial therapist rather than followed from a video. Gentle facial massage for Bell’s palsy is often included in a prescribed programme to ease tightness and maintain tissue mobility, but technique matters and it should be shown to you rather than improvised. Facial Palsy UK maintains resources and a therapist directory.

Muscle-relaxing injections

Where synkinesis or tightness has developed, small doses of muscle-relaxing injections can be placed into the overactive muscles to reduce unwanted pulling and improve symmetry at rest and in movement. Effects build over one to two weeks and typically last three to four months, so treatment is repeated.

Injections are sometimes also used on the unaffected side to reduce its pull and balance the face. This is a considered clinical decision rather than a cosmetic one. Our guide to muscle relaxing injections for medical reasons covers this use in more detail.

How to protect the eye with facial palsy

Eye protection in facial palsy — lubricating drops by day, ointment at night, taping the lid closed and shielding from wind — Eye care is the most important thing you can do yourself. An eye that cannot close is at genuine risk of damage.

This is the single most important practical section on this page. If the eye will not close fully, the cornea is not being covered and lubricated by blinking, and it can dry out, ulcerate and scar. Sight can be permanently affected.

Preservative-free lubricating drops during the day, used often — hourly or two-hourly if needed
A thicker eye ointment at night, which lasts longer but blurs vision, so it is best used before sleep
Tape the eyelid closed at night, using the technique shown to you by a clinician. Done incorrectly, tape can scratch the eye
Wraparound glasses outdoors to shield from wind and dust
Do not patch a partly open eye without advice — a patch pressing on an open eye can cause the very abrasion it is meant to prevent

Seek same-day medical review if the eye becomes red, painful, or vision changes. That is not something to leave until a routine appointment.

Where the eye will not close over a longer period, surgical options exist and are discussed below.

Can you fully recover from facial paralysis?

Most people with Bell’s palsy do, and the numbers are better than most people fear. In the Scottish Bell’s Palsy Study, 94.4% of patients treated promptly with prednisolone had recovered facial function by nine months — and even without steroids, 81.6% recovered (Sullivan et al., 2007 — read the abstract on PubMed, doi:10.1056/NEJMoa072006).

Put the other way round: a minority are left with some degree of lasting weakness, asymmetry or synkinesis. The Cochrane pooled figure puts incomplete recovery at around 17% with steroid treatment and 28% without (Madhok et al., 2016 — read it on PubMed, doi:10.1002/14651858.CD001942.pub5). That residual group is who the reconstructive options further down this page are for.

The outlook is generally better where weakness was partial rather than complete at its worst, where recovery begins within the first three weeks, in younger patients, and where steroid treatment was started promptly.

Other causes carry different outlooks. Ramsay Hunt syndrome recovers less completely than Bell’s palsy. Palsy caused by nerve division during trauma or surgery depends on whether the nerve can be repaired.

How long does recovery take?

Improvement usually begins within two to three weeks and continues over three to six months. Meaningful recovery can still occur up to around twelve months.

That twelve-month mark matters, because it is roughly the point at which the picture is considered settled. What remains after that is usually what you are left with — and it is the point at which reconstructive options become worth discussing. Before then, the priority is protecting the eye and allowing the nerve to recover.

Is Bell’s palsy serious?

Bell’s palsy is not life-threatening and usually resolves. But it is not trivial either. The risks worth taking seriously are eye damage from incomplete closure, and the psychological effect of a changed face — which is frequently underestimated. Difficulty eating, drinking and speaking is common in the early weeks.

Do I need time off work with Bell’s palsy?

Many people take one to two weeks initially, though this varies considerably with the severity and with your job. Roles involving a great deal of speaking, public contact, or working outdoors in wind and dust are harder in the early weeks. Fatigue is commonly reported and often surprises people.

What foods should I avoid with Bell’s palsy?

There is no evidence that any particular food causes or worsens Bell’s palsy, and no diet has been shown to speed recovery. The practical issue is mechanical rather than nutritional: with weak lip closure, thin liquids and crumbly or hard foods are difficult to manage and food tends to collect in the affected cheek. Softer foods, smaller mouthfuls and a straw often help. If swallowing is genuinely difficult, ask to be referred to a speech and language therapist.

Facial palsy treatment in children

Facial palsy in children is managed by paediatric services, and the assessment differs from that in adults — a higher proportion of cases have an identifiable underlying cause, so investigation tends to be more thorough. Recovery from childhood Bell’s palsy is generally very good.

Centre for Surgery does not consult with or treat anyone under 18. Children with facial palsy should be seen through their GP and paediatric or ENT services.

Facial palsy surgery: what a plastic surgeon can treat

Where recovery has plateaued — generally after around twelve months — and functional or appearance-related problems remain, reconstructive surgery can help. This is where a plastic surgeon’s involvement begins, and it is worth being clear about scope.

Surgery does not restore the face to exactly how it was before. The aim is to improve function, protect the eye, and restore balance and symmetry. Expectations need to be set honestly, and any surgeon who suggests otherwise is overpromising.

Eyelid surgery and eye closure

Where the upper lid will not close, a small weight can be placed inside it so that gravity assists closure. Where the lower lid has sagged or turned outward — ectropion — it can be tightened and repositioned to restore contact with the eye. Upper blepharoplasty may be appropriate where excess skin contributes, though technique differs considerably from routine cosmetic eyelid surgery, because lid closure must be preserved rather than tightened away. Our guide to droopy eyelids and ptosis explains the related mechanics.

Brow lift

A drooped eyebrow can obstruct the upper visual field as well as affecting appearance. A brow lift on the affected side can restore position and symmetry. See also our guide to how to fix a drooping eyebrow.

Static procedures for facial support

Static procedures improve position and symmetry at rest but do not create movement. They include suspending the corner of the mouth, and facelift techniques adapted to lift and support the affected side. Facial fat transfer can restore volume where muscle has wasted.

These are often the right choice for older patients, for those who do not want extended surgery, or where dynamic reconstruction is not appropriate.

Dynamic reconstruction

Dynamic procedures — collectively known as facial reanimation surgery, and often called smile surgery — aim to restore movement rather than just position. Depending on the cause and how long the facial paralysis has been present, options include nerve grafting or nerve transfer to reinnervate existing muscle, and muscle transfer where the original muscle is no longer viable.

This is specialist reconstructive work with a long recovery, and suitability depends heavily on the cause, the time elapsed and the condition of the facial muscles. It is assessed case by case rather than offered as a standard package.

Improving facial symmetry

Many people’s main concern once recovery has settled is asymmetry rather than function — most often an uneven smile, or asymmetrical lips where the marginal mandibular branch has not fully recovered. Our guide to facial asymmetry and how to fix an asymmetrical face covers the broader picture, including causes unrelated to facial palsy and the full range of treatments.

What to expect at a consultation

An assessment for facial palsy at Centre for Surgery involves establishing the cause and confirming it has been properly investigated, how long the palsy has been present and whether recovery is still occurring, a graded assessment of movement in each part of the face, an assessment of eye closure and eye health, and a discussion of which problems matter most to you.

Where the palsy is recent, or where the cause has not been established, we will say so and refer you back to appropriate medical care rather than proceeding. That is the right answer in a meaningful proportion of enquiries.

All surgery is performed by GMC-registered plastic surgeons at our CQC-regulated hospital at 95-97 Baker Street, under TIVA or local anaesthetic as appropriate.

Frequently asked questions about facial palsy

Is facial palsy a stroke?

Not usually, but it can be, and the two cannot be told apart reliably at home. Call 999 if facial weakness is sudden and the forehead is also weak, or if there is arm weakness or speech difficulty. In Bell’s palsy the forehead is typically involved along with the rest of that side; in stroke the forehead is often relatively spared, and there are usually other signs.