For patients living with facial paralysis, particularly those recovering from Bell’s palsy or other facial nerve injuries, synkinesis can feel like an unexpected and frustrating turn in the recovery journey. Many are told, “Give it time—it’ll get better.” But as those months turn into years, new, involuntary facial movements begin to emerge when patients perform voluntary motions—smiles that cause eye closure, blinking that pulls up the lip, puckering the lip like a kiss, which causes the eye to close or brow to pull up or down.
These are not signs of normal healing, but rather abnormal facial nerve recovery—signs of synkinesis. The big questions remain: Does it worsen over time? Will it stabilize at some point?
Our recent study, “The Natural Progression of Synkinesis: A Longitudinal Study,” offers the most detailed look to date at how synkinesis evolves. It’s a question that has not been answered definitively until now, and the findings may change the way we think about the timing and importance of early treatment.
Understanding Synkinesis
Synkinesis is likely partly the result of misdirected regrowth of facial nerve fibers after injury. Instead of each nerve fiber returning to its original muscle group, some grow into neighboring territories. That’s why you might blink when you try to smile, or feel your neck tighten when raising your eyebrows. It’s not in your head—it’s in your neuromuscular wiring.
But what happens after that miswiring settles in? Do these movements fade away? Do they plateau? Or do they continue to worsen?
Key Findings From Our Study
In our retrospective cohort of patients diagnosed with post-paralysis synkinesis, we followed 83 individuals who had not yet undergone any treatment. All were assessed using the eFACE scoring system, a tool that objectively measures facial function.
The results were interesting and helpful to our understanding of the natural evolution of facial synkinesis:
- Synkinesis worsens in its initial period. In most patients, synkinesis develops the fastest between 200 to 300 days after the injury and tends to stabilize after 500 days.
- No evidence of natural improvement. After about 500 days from the time of facial nerve injury, the synkinesis seems to stabilize and not show further signs of worsening. That said, no signs of spontaneous improvement were observed even in patients with 10 or 20 years of synkinesis.
This study is the first to provide evidence-based, longitudinal data on the previously unknown natural progression of synkinesis, demonstrating that synkinesis tends to worsen within the first 400 days after facial nerve injury but remains largely unchanged after 500 days.
with permission of Shai M. Rozen, MD for Medical Education and Research. All rights reserved.
What This Means for Patients
If you are experiencing signs of synkinesis—such as eye narrowing when smiling, elevation or depression of the brow when smiling or puckering the lip, or dimpling of the chin, or facial tightness—you are not alone. And you are not imagining things. The changes you’re noticing are real and represent synkinesis, which is caused by abnormal recovery of the facial nerve after injury.
However, there is good news: treatment options are available for synkinesis, which may improve your overall facial function, appearance, and facial balance.
At UT Southwestern and the Facial Paralysis & Reanimation Clinic, we focus on highly individualized treatment strategies for synkinesis. These may include:
- Surgical options in selected cases, including selective neurolysis and myectomy
- Targeted chemodenervation (Botox®) to reduce unwanted muscle contractions
- Physical retraining therapy with facial neuromuscular re-education
The following photos of a 62-year-old woman demonstrate the progression and subsequent plateau of synkinesis severity.
Used with permission of Shai M. Rozen, MD for Medical Education and Research. All rights reserved.
Final Thoughts
As a surgeon and researcher deeply committed to improving the lives of those living with facial paralysis, I believe it is our responsibility to move beyond passive observation. Early communication with a facial nerve surgeon may provide a deeper understanding of facial synkinesis for the patient and better knowledge of the available treatment options. The data from this study teaches what to expect in terms of natural progression of synkinesis and when synkinesis stabilizes.
If you or a loved one is experiencing facial synkinesis, know that help exists, and we are here to guide you through the process with expertise and compassion.
— Dr. Shai M. Rozen
Board Certified Plastic Surgeon
Professor and Vice-Chair of Plastic Surgery, University of Texas Southwestern Medical Center
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