Facial palsy recovery will usually follow one of the two recovery scenarios, depending on the scale of initial damage to the facial nerve. If the damage was light, the recovery will be quick, and if the damage was more severe, then the recovery will need a longer time.
In most cases, after Bell’s palsy, a quick recovery happens within a few weeks and usually leads to a full return of facial movements. However, in approximately 20-30% of the cases, the recovery can take a significantly longer time and lead to the development of unwanted complications.
In this article, we will discuss a general timeline of a long recovery after Bell’s palsy and explain why it takes more time.
According to medical definitions, Bell’s palsy is a diagnosis of exclusion for a peripheral, unilateral facial palsy. It is given when the cause of the facial palsy cannot be determined. However, in folks’ mouth, Bell’s palsy is commonly used to describe any kind of peripheral facial palsy and is often used interchangeably with facial palsy to mean the same underlying condition – a unilateral paralysis of facial muscles. In this article, we will follow the general habit of interchanging the terms for simplicity of understanding.
Please note that in this article, we discuss classical facial palsy. We will discuss recovery possibilities after congenital, post-traumatic, or post-operational facial palsy in another article (coming soon).
The contents of this article are based on our experience with numerous patients that visit our clinic for rehabilitation, sign up for a video consultation, or contact us for more information on their cases. The information below is meant to describe the most typical scenario. Each facial palsy case is unique and will unfold in an individual way. Nonetheless, you can reasonably expect your recovery to follow the direction described here.
Table of contents
Estimated reading time: 12 minutes
When to expect a long recovery?
The length of recovery after Bell’s palsy depends on the scale of damage the facial nerve had sustained. In the majority of Bell’s palsy cases, the damage to the facial nerve will be superficial, and the nerve will recover within a few weeks. We discuss this scenario in detail in the article “Quick Bell’s Palsy Recovery Timeline“. In some cases, however, the damage to the nerve can be more severe and the facial nerve needs a much longer time for recovery.
What causes a long recovery after Bell’s palsy?
To understand why the recovery after Bell’s palsy sometimes takes a longer time, let’s look at what happens to the facial nerve immediately before the onset of paralysis and after it.
Our facial nerve is made up of motor neurons to the most part, as well as some sensory neurons and parasympathetic fibres. The main task of a motor neuron is to transmit electrical signals from our brain to the muscles. In our case – the facial muscles. Once the signal reaches the muscle, the muscle fibres will contract, and when the signal from the brain is absent, they relax.
The electrical signal produced by the brain will travel along the axon of the motor neuron. To be able to transmit the signal, the axon is insulated by myelin sheath – just like any electrical wire has to be insulated in order to conduct electricity properly.
When Bell’s palsy happens, the facial nerve becomes damaged and its ability to transport electrical signals is compromised, Bell’s palsy happens. Under the impact of damaging factors, both the myelin sheath and the axon may sustain damage. Depending on the parts of the nerve fibres that were damaged, your recovery will either be short or will take a longer time.
Your recovery will take a long time if the damage to the facial nerve was extensive.
In general, peripheral facial palsy is caused by swelling of tissues surrounding the facial nerve or by a disrupted blood supply. When the swelling develops, it will compress the facial nerve (Stage 1 on the image below), reducing the supply of oxygen and damaging the tissues. Without oxygen, both the myelin sheath and the axon can become damaged rather quickly.
Following the compression, the myelin sheath will be damaged first (Stage 2). Without the insulation of the myelin sheath, the facial nerve cannot conduct the electrical signals, so the brain loses connection with the facial muscles. This is called a conduction block. If at this early point the compression is eliminated with the help of steroids or natural mechanisms of our body, the fibres of the facial nerve will remain undamaged. In this case, you will most likely follow a quick recovery timeline that will result in a full spontaneous return of facial movements.
However, if the compression remains for a longer time (5-6 days or more), not only the myelin sheath but also the fibres of the facial nerve will sustain damage (Stage 3). This leads to degeneration of the facial nerve fibres (Stage 4).
This means that to re-establish the connection between the brain and the facial muscles, your body needs to regenerate both the degenerated facial nerve fibres and myelin sheath. This is what causes your recovery to be long. The facial nerve fibres will regenerate, in the most optimal conditions, at the rate of not more than 1mm per day. Having to regenerate around 80-100mm of distance, it may take at least several months before the first movements will appear. Some nerve branches can regenerate sooner, while others might need more time. For example, you might notice some movements in your forehead but will need to wait a few more weeks before you can see some movements in your mouth corner.
If the recovery takes a longer time (several months), the probability of developing some form of complications, such as synkinesis, facial asymmetry, crocodile tears, contractures of facial muscles, and others, is quite high. The good news is that in most cases, these complications and residuals can be reduced with the help of proper rehabilitation, as evident from the experience of our patients.
What can be done to avoid a long recovery?
The most important first step, when you realize that you have facial paralysis, is to go to your doctor as soon as possible. This is a time-sensitive issue, and the sooner your doctor will establish the damaging factor, the sooner you can begin any required medications to help you reduce the compression of the nerve trunk.
Unfortunately, there are very limited steps we can take to reduce the possibility of extensive damage to the facial nerve fibres. To a large extent, the damage depends on the factors that caused facial palsy in the first place.
In cases such as Ramsay Hunt Syndrome – where the facial palsy is caused by a Herpes Zoster virus – the recovery will usually take a longer time. That is because viral or bacterial infections that cause local swelling around the facial nerve and result in facial palsy can take at least a few days to be cured. Until the infection is taken care of, the swelling cannot be reduced effectively, so the facial nerve will sustain extensive damage.
Long Bell’s palsy recovery timeline
Here we are describing the average recovery scenario. Although the length of each stage might vary from person to person, the stages will generally follow the same pattern and order.
In this timeline, we use photos of a fellow Bell’s palsy sufferer – Jay – who documented the whole recovery process from day 1 using Neurological tests. He has kindly given us permission to use his photos to illustrate the recovery process. Please, do not reuse these photos without Jay’s permission. For illustrative purposes, the dates of Jay’s progress were adapted to fit the scenario described.
Your facial palsy begins and the full paralysis of one side of the face takes place. Paralysis occurs due to compression of the facial nerve.
What to do: go to your doctor or the ER as soon as possible. The damaging factor that causes the swelling (such as local overcooling, viral or bacterial infection, etc.) has to be eliminated as fast as possible to prevent heavier damage to the facial nerve. Follow your doctor’s instructions, take a lot of rest, and sleep enough.
This period can be very hard emotionally, but please do not panic or despair. Your face will not remain like this forever. Knowing what is happening to you will help you to stay calmer, so look through our Bell’s Palsy Knowledge Base to educate yourself.
Most likely, there will still not be any visible movements.
What to do: continue following your doctor’s advice and take any prescribed medications. Be patient, the recovery may take some time. Do soft facial massages, protect your eye from drying, apply a warm compress and refrain from stress (emotional and physical).
If you notice some form of recovery signs (some tingling, tickling or vibrating sensations in your facial muscles) during these days, then most probably you are following a quick recovery scenario.
If both the myelin sheath and the facial nerve were damaged, it will take some time until the first recovery signs might appear. From now on until the first recovery signs you will not see any changes. It should not be getting worse, but it will also not improve until the facial nerve regenerates enough to be able to reconnect with the fibres of facial muscles.
Be patient. It is a hard journey, but remember that your body is doing all it can to recover the damaged facial nerve. You need to support it by avoiding wasting its resources through stress. Follow a healthy lifestyle, do facial relaxations, and also try to balance your emotions.
What to do: continue what you were doing before. It is extremely important to avoid forcing your face into facial expressions to see if you can make it move. Keep your facial muscles relaxed as much as possible. The movements will come when the facial nerve recovers sufficiently. Until then, no matter how much you try, you will not be able to force your muscles to move (the signals from the brain cannot reach the facial muscles, no matter how strong the signals are). Check our Bell’s Palsy Knowledge Base for more recovery tips.
Important note: during any peripheral facial palsy (as long as it was not caused by injury to the head), your facial muscles remain healthy. They are not involved in the facial palsy process and do not suffer from atrophy. You can read more about it in a dedicated article – “Can facial muscles atrophy during Bell’s palsy?“.
From week 3 through week 12
Somewhere within this time, the first movements should appear. Depending on the scale of initial damage and regenerative capacity of your body, the first movements tend to manifest themselves somewhere between week 6 and week 12. It may still take some time for the facial nerve and the myelin sheath to recover fully. After you see the first movements, most of the remaining movements should return within the next 4-8 weeks approximately.
At this stage, the forming of complications such as synkinesis and excessive tone of facial muscles is to be reasonably expected. After 8-9 months since the onset, both positive and negative changes will slow down. All the changes after that will be happening very gradually. By the end of 10-14 months since the onset, your recovery will stabilize and reach its final result. After this mark, to achieve any further improvements you will need to follow professional rehabilitation and guidance. Without any help, further improvements may be very marginal and barely noticeable.
What to do: continue what you were doing before, with the emphasis on more regular facial massages and relaxation.
Bell’s palsy does not last forever.
It is very important to remember that Bell’s palsy does not last forever. Since the time when the first movements appear, your facial palsy ends. From now on, you are not suffering from Bell’s palsy any longer. Your recovery may be incomplete, and you may experience complications and residuals, but it is no longer Bell’s palsy itself – it is the complications after a long recovery period.
After the first movements appear
After a long-term recovery, when the movements begin to return, it is most likely, that at the end, your mimetic functions on the affected side will not go back to the same way they were before. There are a few reasons for this:
- some of the facial nerve fibres have not (yet) regenerated fully,
- you developed complications and residual effects during the long recovery period.
The most common complications that may form after a long Bell’s palsy recovery process are synkinesis, asymmetric smile, chronic facial pains and tensions, increased tone of facial muscles, crocodile tears, and others. Still, this is not a reason to despair.
In most cases, it is possible to reduce their manifestation, including synkinesis, by following a well-guided rehabilitation program and working on improving your facial condition every day. Some of our patients have shared their recovery journeys to give you hope and make you believe that it does not have to stay this way.
It is not an easy journey, but if you are motivated to bring your smile back, we are ready to share our knowledge and guide you to the best of our abilities. Speak with us.
– Alex Pashov
Crystal Touch Bell’s palsy clinic