Once synkinesis has occurred, treatment relies on three distinct modalities: neuromuscular retraining (physical therapy), Botox (botulinum toxin) and surgery. Treatment of synkinesis can be initiated at any time after its occurrence. This may be even years after a patient has suffered Bell’s palsy or facial paralysis.
Neuromuscular retraining and physical therapy for synkinesis is very different than what is performed for other medical problems. Facial neuromuscular retraining is more comparable to a vocal therapist that is treating a singer who has hoarseness or poor mechanics. Facial neuromuscular retraining is primarily focused on coordinating appropriate facial muscle movements. This is achieved by inhibiting the activity of the abnormal movement patterns, resulting in “auto-paralysis” of unwanted muscles.
The muscles that are contracting abnormally are first identified. Muscles that are contracting out of sequence are inhibited. Small steps are usually taken in order to gradually retrain the muscles, as there needs to be significant changes at the neurologic (brain) level for success. Electrical stimulation is avoided as it tends to increase the overactive muscles. Muscles that are extremely overactive in the cheek and neck are actively massaged and stretched. Patients are discouraged from undergoing strong muscle strengthening exercises, as again this is more about re-coordination rather than stimulation. Patients are also taught how to elevate the upper eyelids during eating to reduce the eye synkinesis. Ninety percent of the therapy exercise can be done by the patient at home. Other treatment modalities will focus on mirror and video exercises.
The second mode of therapy for synkinesis is Botox (botulinum toxin-A). Botox is used in conjunction with facial neuromuscular therapy in most cases. Botox works by reducing the activity of the muscles that are overactive or uncoordinated. Most common areas of injection are eye muscles (orbicularis), neck bands (platysma), and chin dimpling (mentalis). Botox can also be used to symmetrize the face by reducing the activity of certain muscles on the normal side of the face such as: forehead, lower lip depressors (depressor anguli oris) and crow’s feet (orbicularis).
The final modality for treating synkinesis is surgery. Surgery is utilized only when physical therapy and Botox have been unsuccessful in obtaining the desired results. Selective neurolysis is the latest advancement in the treatment of synkinesis. During this surgery, the surgeon releases the platysma muscle and decreases the activity of the nerves that pull the mouth downward to allow for the mouth corners to once again turn upward. The procedure is complex, but the recovery period is similar to that of a facelift. Static suspension of the corners of the mouth, blepharoplasty (eyelid surgery), and facelift are also commonly utilized to address synkinesis.