Early management of post-operative facial weakness

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1 Physiotherapy Department Early management of post-operative facial weakness What is post-operative facial weakness? In order to move your face, messages are sent from your brain to your facial muscles along a nerve called the facial nerve. The right and left facial nerves connect from each side to your facial muscles, which allow you to smile, frown, close your eyes and so on. Ref: During surgery, the facial nerve can become bruised, stretched or cut. When this happens the nerve will not send messages to the muscles properly. This can lead to facial weakness resulting in problems with facial movement and other symptoms, such as: a floppy cheek eye or mouth droop difficulty closing your eye fully. It is sometimes difficult to know for certain whether the nerve is just bruised or whether it is more severely damaged. The length of time it takes for you to show any signs of recovery will help us determine the extent of the nerve damage. It can also sometimes take a long time to establish whether or not the nerve will heal. 1 of 6

2 Early management is the most effective way for you to manage facial weakness. This can be achieved by: Eye care Aiming for symmetry when your face is at rest Mouth care Massage Gentle stretches Gentle exercises Normal eating and talking The goals of this early management are to try to reduce the likelihood of developing longer-term problems and to promote good conditions for nerve recovery. Aiming for symmetry at rest Try to relax the unaffected side of your face so the middle of your face isn t pulled across. It is helpful to use a mirror to guide you. Mouth care If your cheek is floppy you may be at risk of biting your cheek or lip, or getting food caught near your gum. This can lead to infection in the mouth if food residue is not properly cleared. General advice for mouth care: Rinse your mouth out with water or a specified mouthwash regularly. Brush your teeth after meals. If necessary, gently use your finger to hook out any food left behind. Eating and talking You may find eating and talking more difficult if your cheek is floppy or if your lips are weak on the affected side. Eating and talking as normally as possible is good exercise for your facial muscles and helps to promote recovery. If eating/talking is a problem for you, the speech and language therapist (SLT) may be able to offer specific advice. If you would like to see a speech and language therapist, ask your health professional if they can refer you. Try to chew using both sides of the jaw (avoid just chewing on the one side). Normal use of the face where possible will help recovery. It may help to support your cheek with your hand when talking. Eye care Closing your eyes and blinking helps to keep the eye clean and moist to prevent damage. If your eye does not fully close, you may need specific care or treatment to ensure your eye remains healthy, especially to prevent damage at night. Your doctor will recommend the most appropriate treatment for you. Possible treatment options include: taping the eyelid closed at night (see below for advice on this technique) eye drops placing a moisture chamber over the eye an eye patch. 2 of 6

3 You may be advised to use your finger to do a blink for the affected eye (see gentle exercises for instructions). General advice for eye care Wear sun glasses in bright light. Eye taping technique: If your lower lid has dropped, use a small diagonal piece of soft Micropore tape to support the lower lid and raise it up (as in picture A). Then use the manual blink instructions on page 5 to lower your top lid and tape over vertically from top to bottom keeping eyelashes clear of the eye (as in picture B). There are variations on this technique. For some people just the vertical tape (picture B) may be effective. Other suggestions may be more appropriate to you as an individual speak to you health professional if you have concerns. A There are also longer-term options available, which can be discussed as required with your surgeon or ophthalmologist (eye doctor). Gentle stretches Because some muscles, particularly on the unaffected side can remain very active, without resting they can become short and tight. There may be some stretches you can do to prevent this. General advice for gentle stretches: If you have had eye surgery, do not do this without checking with your surgeon that it is ok to do so. S1) For tightness around the eye, use your fingertips to gently hold the eye closed and gently raise the eyebrow using the fingertips of the other hand, until you feel a stretch. S2) Use your fingertips to stretch your nose towards the weaker, affected side. S3) Use your fingertips to stretch your lip towards the weaker, affected side. S4) With your finger, sweep the inside of your cheek, from back to front, beginning with the stronger side and repeat with the weaker side. 3 of 6

4 S1) S2) S3) S4) Massage When your facial muscles move, the overlying skin moves with them and this is how you feel or sense the movement. Most of the feeling in your face is supplied by a different nerve to the one that makes the muscles move, but sometimes this sensory nerve can also be affected. To help encourage your awareness of facial movement when the nerve is still recovering, it may be helpful to do some gentle massage. General advice for facial massage: If you have had a nerve graft, do not do this without checking with your surgeon that it is ok to do so. M1) Use gentle circular motions with your fingertips at the front of your scalp (as if washing your hair), work down towards your forehead, around your eyes, nose and mouth, down as far as your neck. M2) Use gentle upwards stroking movements on the weaker, affected side. M3) Use gentle downward stroking movements on the unaffected side. M1) M2) M3) 4 of 6

5 Gentle exercises Exercises will not speed up the recovery of the nerve, but the movement will help to prevent muscle-wasting, which can contribute to the nerve-related facial weakness. Any exercises need to be gentle. None of your movements should be exaggerated you should just use your face as normally as possible. Try not to over-compensate with over-activity of the unaffected side. Use a mirror and aim for symmetry. E1) The manual blink: Look down and close both eyes simultaneously. You can roll your finger down over the lid of the weaker, affected side to help it close fully. E2) The eyebrow raise: Gently raise your eyebrows using your fingertips to help the eyebrow on the weaker side. E3) Corner of mouth: Smile, using your fingertips to lift the corner of your mouth on the weaker side. E4) Sniff and gently support the skin around your cheeks so they are even. Hold for one second then relax. E5) Spread your lips as if saying ee. Gently pull on the weaker side until it is symmetrical with the stronger side. E6) Purse your lips. Gently push the weaker side until your mouth is even. Hold for one second then relax. E1) E2) E3) E4) E5) E6) Do each of these at intervals through the day. If you prefer, you could repeat them five times in one go, three times a day. 5 of 6

6 Jaw exercises Sometimes, the movement of your jaw can become restricted after surgery. This can lead to problems, such as not being able to open your mouth enough to eat, speak, clean your teeth or be examined. Be aware of how much your mouth can open a good test of this is to see how many fingers you can stack between your front teeth or gums. Practise this every day until your treatment is fully complete. Will I have a follow-up appointment? Depending on the extent of the nerve injury and the expected recovery, the team may arrange a physiotherapy follow-up appointment for you. This will be discussed with you before you go home from hospital. In the case of mild nerve injury, where it is thought to be bruising only, you can expect things to return to normal in around 6 8 weeks. You should use the care advice listed above during this time. If you have ongoing concerns after that time and have not been referred for physiotherapy, please discuss referral with your surgeon/doctor. Contact us If you have any questions or concerns about facial weakness or physiotherapy following your surgery, please contact the Blundell Ward physiotherapist on or Alternatively, if you are known to the Community Head and Neck Team (CHANT), you can call the CHANT physiotherapists on Please leave a message if your call is not answered and someone will call you back. Opening hours are 8.30am to 4.45pm, Monday to Friday. Useful sources of information Websites: Pharmacy Medicines Helpline If you have any questions or concerns about your medicines, please speak to the staff caring for you or call our helpline. t: am to 5pm, Monday to Friday Patient Advice and Liaison Service (PALS) To make comments or raise concerns about the Trust s services, please contact PALS. Ask a member of staff to direct you to the PALS office or: t: at St Thomas t: at Guy s e: 6 of 6 Leaflet number: 3765/VER1 Date published: August 2013 Review date: August Guy s and St Thomas NHS Foundation Trust

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