What is Selective Neurolysis?

Synkinesis is primarily diagnosed through a clinical examination conducted by a physician specializing in facial nerve disorders. Diagnosis involves a comprehensive physical assessment of facial nerve function and observation of involuntary muscle movements that occur during voluntary facial expressions. Patients are asked to perform specific facial movements—such as smiling, puckering their lips, or closing their eyes—while the physician monitors for unintended muscle contractions in other areas of the face. 

To enhance accuracy and documentation, digital photography and video recordings are often used to capture subtle signs of synkinesis. Standardized tools, such as the Sunnybrook Facial Grading System (FGS) and the Synkinesis Assessment Questionnaire (SAQ), are commonly utilized to assess the severity and impact of the condition. In some cases, electromyography (EMG) may be used to provide additional insights into muscle activity, but it is typically not required for diagnosis. This thorough approach ensures a detailed understanding of the patient’s condition, guiding appropriate treatment planning. 

An electromyography (EMG) is not typically required before undergoing selective neurolysis surgery. While EMG can provide valuable insights into facial nerve function and muscle activity, it is not a mandatory step for most patients. Synkinesis, the primary condition that makes you a candidate for selective neurolysis, is usually diagnosed through a clinical examination by an experienced facial nerve specialist. During your preoperative evaluation, the surgeon will assess your facial movements and synkinesis patterns to create a customized surgical plan. 

EMG may occasionally be recommended if your surgeon needs additional information about nerve regeneration or muscle activity patterns. This decision is based on individual factors, such as the time since the onset of your facial paralysis, the severity of your synkinesis, and your specific goals for surgery. An EMG works by using small electrodes to measure electrical signals in your muscles, providing detailed data on how your facial nerves and muscles are functioning. While not required in most cases, it can be a helpful tool in certain complex situations to guide treatment planning. 

Dr. Azizzadeh does not identify a specific ideal age for undergoing selective neurolysis, as the procedure can benefit both younger and older patients whose synkinesis has stabilized—typically at least one year after the onset of facial paralysis. This includes cases resulting from conditions such as Bell’s palsy, Ramsay Hunt syndrome, Lyme disease, acoustic neuroma surgery, or facial trauma. The suitability of the surgery depends more on a patient’s overall health and ability to tolerate general anesthesia rather than their age. Additionally, candidates should have realistic expectations and the psychosocial stability to manage outcomes, which may sometimes be less than perfect. A comprehensive evaluation by an experienced facial paralysis specialist, like Dr. Azizzadeh, is essential to determine whether selective neurolysis is the most appropriate approach for each individual’s unique situation. 

Selective neurolysis and selective denervation refer to the same procedure, both targeting abnormal nerve regeneration to address facial nerve dysfunction from synkinesis. This innovative technique, pioneered by Dr. Babak Azizzadeh, has become a leading approach in treating synkinesis and facial paralysis. Although the terminology may be confusing, they describe the groundbreaking concept Dr. Azizzadeh developed to improve smile and quality of life outcomes for patients who did not recover from bell’s palsy, ramsay hunt syndrome, lyme disease, acoustic neuroma, trauma and other forms of regenerative facial nerve disorders. Selective neurolysis involves precise mapping of facial nerve branches and selectively modulating those responsible for unwanted movements, restoring more natural facial expressions and symmetry. With unparalleled experience in this field—having performed more of these surgeries than any other surgeon worldwide—Dr. Azizzadeh combines his deep understanding of facial nerve anatomy, function, and aesthetics to deliver exceptional results. His compassionate, patient-centered approach further enhances the overall experience and quality of life for individuals seeking to regain facial animation and confidence. 

Depressor anguli oris (DAO) resection and selective neurolysis are distinct procedures that address different aspects of facial nerve dysfunction, making it inappropriate to claim one is universally better than the other. Selective neurolysis, pioneered by Dr. Babak Azizzadeh, offers a comprehensive approach to treating synkinesis caused by conditions such as Bell’s palsy, Ramsay Hunt syndrome, or Lyme disease. By targeting the root cause of facial asymmetry, this procedure addresses disorganized nerve growth and hyperactivity across multiple muscles, including the platysma, DAO, buccinator, mentalis, and smile muscles, often resulting in more significant improvements in facial function and symmetry. 

In comparison, DAO resection focuses specifically on one muscle and may be less effective for managing the broader complexity of synkinesis. However, Dr. Azizzadeh has developed a novel approach to DAO resection that enhances its ability to contribute to a more comprehensive smile improvement. He is set to publish his innovative technique, which will further expand the options for patients seeking advanced facial reanimation. 

Dr. Azizzadeh typically recommends selective neurolysis as the primary surgical option, using DAO resection as a complementary procedure to refine outcomes alongside botulinum toxin treatments. In some cases, DAO resection may be performed first or concurrently with selective neurolysis, depending on the patient’s specific condition and goals. 

Dr. Azizzadeh’s expertise in both procedures, as well as in other advanced facial reanimation techniques such as gracilis muscle transfer, masseteric facial nerve transfer, and temporalis tendon transfer (Labbé procedure), allows him to create highly personalized surgical plans. This tailored approach ensures that each patient receives the most effective treatment for their unique facial nerve dysfunction and aesthetic needs. 

Yes, it is absolutely possible, and in fact, many patients visit Dr. Babak Azizzadeh because they were unable to achieve comprehensive smile outcomes with DAO resection alone. Dr. Azizzadeh, the pioneer of selective neurolysis, often sees patients seeking more extensive improvements in smile function and facial symmetry following prior procedures. 

Selective neurolysis addresses the root cause of facial nerve dysfunction by targeting abnormal nerve regeneration and reducing unwanted muscle activity, providing a broader and more effective treatment for synkinesis and facial paralysis. In contrast, DAO resection focuses on refining smile mechanics by reducing the downward pull of specific muscles around the mouth. DAO resection is definitely a useful tool in the armentarium of facial reanimation expert and can complement the outcomes of selective neurolysis; however, it is typically more effective as part of a combined or staged approach. 

Dr. Azizzadeh usually performs selective neurolysis first to optimize overall facial function and symmetry. After evaluating the results, he may recommend DAO resection or other adjunctive procedures to further enhance smile symmetry and oral function. This personalized treatment strategy allows Dr. Azizzadeh to tailor the approach to each patient’s unique anatomy and goals, ensuring the best possible outcomes. By combining selective neurolysis with DAO resection when needed, patients can achieve more natural facial expressions, improved smile mechanics, and balanced facial symmetry. 

Yes, it is possible to undergo depressor anguli oris (DAO) resection after selective neurolysis. Dr. Babak Azizzadeh, the pioneer of selective neurolysis, may recommend performing DAO resection after or in conjunction with selective neurolysis to achieve optimal results in treating facial synkinesis and paralysis. 

Unlike DAO resection, selective neurolysis addresses the root of facial nerve dysfunction and synkinesis by targeting multiple nerves and muscles affected by disorganized nerve regeneration. In contrast, DAO resection specifically focuses on reducing overactive muscle activity responsible for pulling the corners of the mouth downward. By prioritizing selective neurolysis, Dr. Azizzadeh can first evaluate the overall improvement in facial function and symmetry, determining whether additional procedures, such as DAO resection, are necessary to refine the results. In many cases, DAO resection may never be required; however, for some patients, this staged or combined approach provides a highly tailored treatment plan that addresses their unique needs. This strategy can lead to more natural facial expressions, enhanced smile mechanics, and improved overall facial symmetry. 

Yes, a modification of the  deep plane facelift can absolutely be performed at the same time as selective neurolysis. In fact, Dr. Babak Azizzadeh, a pioneer in facial paralysis treatment, performs this combination in approximately 50% of his selective neurolysis cases. This approach, which Dr. Azizzadeh has published on and termed “symmetrical facial repositioning,” addresses both the asymmetry and aesthetic aspects of facial paralysis and synkinesis. 

The combined procedure not only improves facial nerve function but also enhances overall facial symmetry and harmony. Dr. Azizzadeh may incorporate additional techniques such as fat grafting, buccal fat repositioning, and asymmetric blepharoplasty to further refine results. These complementary procedures are particularly beneficial because patients with synkinesis who often experience accelerated aging on the unaffected side, as well as asymmetry in soft tissues and fat compartments even without aging. By addressing both the underlying nerve dysfunction and the resultant soft tissue changes, Dr. Azizzadeh can achieve more comprehensive and aesthetically pleasing outcomes for his patients. 

In most patients with synkinesis, the eyelids tend to overly narrow due to aberrant regeneration of facial nerve fibers, causing overactive and involuntary contraction of the orbicularis oculi muscle during smiling or other facial movements. This condition contrasts with the inability to close the eyes seen in full paralysis, where the nerve supply to the eyelid muscles is entirely disrupted. 

Botulinum toxin injections, such as BOTOX®, Dysport®, or Xeomin®, remain the most effective treatment option for managing eyelid narrowing caused by synkinesis. These injections help relax the overactive orbicularis oculi muscle, reducing involuntary contraction and improving eyelid symmetry and function.  For patients with moderate to severe synkinesis, Dr. Babak Azizzadeh may also recommend orbicularis muscle resection in addition to botulinum toxin. He has recently published a novel technique for orbicularis muscle resection, sometimes performed in combination with selective neurolysis, browlift, and blepharoplasty, to improve function, symmetry, and aesthetics. While all surgical procedures carry some level of risk, patients severely affected by synkinesis may opt for these interventions to achieve meaningful improvement. 

However, treatment around the eyes requires a conservative approach due to the delicate nature of the area and the critical need to preserve eye function and protection. Dr. Azizzadeh carefully tailors each treatment plan based on the severity of symptoms, patient goals, and a thorough discussion of the potential risks and benefits, ensuring the best possible outcomes while prioritizing safety. 

General anesthesia is the preferred method for performing selective neurolysis to treat facial synkinesis. Dr. Babak Azizzadeh favors this approach because it enables optimal facial nerve monitoring during surgery, which is critical for ensuring both safety and effectiveness. General anesthesia eliminates the need for local anesthetic injections, such as lidocaine, which can interfere with nerve and muscle activity. This allows for precise intraoperative neuromonitoring and detailed evaluation of the micronerve anatomy essential for selective neurolysis. 

Intraoperative facial nerve monitoring is a vital component of selective neurolysis and other facial nerve surgeries. It provides real-time identification and functional assessment of facial nerve branches, helping surgeons navigate delicate structures and minimize the risk of iatrogenic injury. Dr. Azizzadeh uses advanced tools such as the NIM® 3.0 Nerve Monitoring System and Checkpoint® Stimulators and Probes, which offer unparalleled precision. The NIM® 3.0 system detects and records nerve activity during surgery, alerting the surgeon to potential nerve strain or damage, while the Checkpoint® system delivers controlled electrical stimulation to map and evaluate specific nerve branches. These technologies ensure the highest level of accuracy in identifying and modulating nerves responsible for synkinesis. 

General anesthesia is essential for achieving the stillness and unimpeded nerve monitoring required for such precise procedures. It avoids the potential confounding effects of local anesthetic and allows for a meticulous, comprehensive approach to addressing nerve dysfunction. 

For certain procedures, such as DAO resection, blepharoplasty, and orbicularis muscle modification, Dr. Azizzadeh may opt for local anesthesia instead. These surgeries are less reliant on extensive nerve mapping and can be performed effectively without general anesthesia. 

Short answer is no but the majority of patients achieve meaningful improvement in their smile, quality of life and synkinesis.  While maintaining realistic expectations is essential, this procedure has the potential to greatly enhance a patient’s ability to smile naturally and spontaneously.  What sets selective neurolysis apart is its ability to preserve the entire neuromuscular pathway, making it one of the few facial reanimation techniques capable of achieving a truly authentic emotional smile. However, it’s important to recognize that outcomes are highly individualized and may not result in a “perfect” or completely normal smile. Its success heavily depends on the skill of the surgeon, as a highly experienced facial nerve specialist can customize the procedure to address each patient’s specific needs. Results also depend on various factors, including the severity of synkinesis, the patient’s unique facial anatomy, and the expertise of the surgeon. 

While selective neurolysis may not completely restore a “normal” smile in all cases, it remains a highly promising solution for many patients struggling with facial synkinesis. By working with an experienced surgeon and setting realistic expectations, patients can achieve meaningful improvements in their ability to smile naturally, ultimately enhancing both facial function and emotional well-being. 

Selective neurolysis, pioneered by Dr. Babak Azizzadeh, is widely regarded as a safe and effective surgical option for treating facial synkinesis. This outpatient, single-stage procedure has the potential to provide significant improvements in smile function and facial symmetry. Some patients notice improvement immediately after surgery, although final results typically take 12–24 months to fully manifest, as individual healing and nerve adaptation vary. While some patients experience rapid progress, others may have fluctuations in their condition before reaching optimal outcomes. 

As with any surgery, selective neurolysis carries some risks. These include rare complications such as infection, hematoma (a collection of blood under the skin), and scarring. Additionally, while the procedure aims to achieve meaningful improvements, there is a chance that the desired goals may not be fully realized, which could necessitate additional treatments or procedures. One unique risk associated with selective neurolysis is temporary oral incompetence, reported in approximately 10-15% of patients. This condition, which may cause difficulty with certain oral functions, can be especially challenging for individuals recovering from prior facial nerve conditions, such as Bell’s palsy. Although rare, there is also a slight possibility of worsening results. 

Despite these considerations, selective neurolysis is generally well-tolerated, with the vast majority of patients experiencing significant benefits and no major complications. Dr. Azizzadeh’s expertise and meticulous approach help ensure that risks are minimized while maximizing the potential for transformative outcomes. 

The benefits of Selective Neurolysis (synkinesis) can be significant, but the procedure is not intended for every facial paralysis patient. By meeting with Dr. Azizzadeh, you can gain insights into the treatment, how it works, and to see if you are a good candidate for Selective Neurolysis. If you qualify for this surgery, Dr. Azizzadeh will create a personalized treatment plan to achieve the best possible results.

Synkinesis, a common complication of facial paralysis conditions such as Bell’s palsy and Ramsay Hunt syndrome, significantly disrupts the natural smile mechanism. Other causes include facial nerve trauma, surgical complications (e.g., parotid or acoustic neuroma removal), and congenital facial paralysis.  Synkinesis arises from improper facial nerve regeneration, causing overactivity and simultaneous activation of multiple facial muscles that should normally function independently. 

In a healthy facial nerve system, smiling relies on the coordinated activation of specific muscles that lift the corners of the mouth, creating a natural, symmetrical expression. In patients with synkinesis, however, an attempt to smile triggers unintended activation of other muscle groups, including the depressor anguli oris, platysma, orbicularis oris, and buccinators. This aberrant muscle activation results in a smile that appears asymmetric, pulled downward, and unnatural. The spontaneity, symmetry of laugh lines, balanced teeth display, and upward movement typical of a natural smile are compromised in synkinesis. 

Selective neurolysis surgery, performed by specialists like Dr. Babak Azizzadeh, directly addresses this issue. The procedure involves meticulously identifying the facial nerve branches controlling various facial muscles. Success hinges on preserving the nerve branches essential for smiling while selectively reducing the activity of those innervating muscles that negatively affect the smile. This targeted approach addresses the underlying cause of synkinesis, often producing results superior to other treatment options. By rebalancing neural input to the facial muscles, selective neurolysis helps restore a more natural, spontaneous, and symmetrical smile, significantly enhancing both the functional and aesthetic aspects of facial expression for patients with synkinesis. 

Selective neurolysis can effectively address neck pain and tightness associated with facial synkinesis. This surgical procedure targets overactive nerve branches responsible for involuntary muscle contractions, including those affecting the neck area, particularly the platysma muscle. By selectively modulating these nerves, the procedure reduces muscle hypertonicity and unwanted contractions that contribute to discomfort and tightness. 

Dr. Babak Azizzadeh often enhances the outcomes of selective neurolysis by performing platysma muscle resection at the same time, offering an additional level of improvement for patients with significant platysmal synkinesis. Studies have shown statistically significant improvements in symptoms of platysmal synkinesis following modified selective neurolysis and related interventions. 

In some cases, botulinum toxin injections (e.g., BOTOX®, Dysport®) may be used either as a standalone treatment or in combination with selective neurolysis. These injections can provide temporary relief by relaxing the overactive platysma and other affected muscles, making them a versatile option for managing neck tightness and pain. 

It is important to note that the effectiveness of these treatments can vary among individuals. A thorough evaluation by an experienced facial nerve specialist, such as Dr. Azizzadeh, is essential to determine whether selective neurolysis, platysma muscle resection, botulinum toxin injections, or a combination of these approaches is the most appropriate treatment for your specific condition. 

No, synkinesis cannot be completely cured because the core issue lies at the axonal and neurophysiological level, where facial nerve fibers regenerate along incorrect pathways after injury. This “miswiring” leads to involuntary muscle contractions during voluntary movements, creating a condition that is challenging to fully reverse. However, a multimodal approach developed and customized by Dr. Azizzadeh can potentially  improve symptoms and help you regain as much normal facial function as possible. 

The primary goal of treatment is to restore facial symmetry and coordinated movement to a state as close as possible to your pre-paralysis condition. Key interventions include selective neurolysis, which targets overactive nerve branches to rebalance facial nerve input, and botulinum toxin injections to relax hyperactive muscles. Physical therapy, particularly neuromuscular retraining, is critical for improving muscle coordination and reducing involuntary movements by teaching your brain to use the correct pathways more effectively. 

Beyond physical treatments, psychosocial support, relaxation techniques, and meditation are essential for addressing the emotional and psychological effects of synkinesis. Managing the stress and anxiety that often accompany facial paralysis can play a vital role in enhancing your overall recovery and quality of life. 

While a complete cure is unlikely due to the underlying neurophysiological changes, these interventions can work together to provide meaningful improvements. With a comprehensive and personalized treatment plan, patients often experience enhanced facial function, symmetry, and confidence, significantly improving their daily lives. 

Acupuncture may offer potential benefits for treating Bell’s palsy, but the scientific evidence remains inconclusive. Some studies, including randomized controlled trials and meta-analyses, suggest that acupuncture could improve facial nerve function and alleviate symptoms through mechanisms such as reducing inflammation, promoting blood flow, stimulating nerve regeneration, and enhancing muscle function. However, these findings are limited by methodological issues, including small sample sizes, high risk of bias, and inconsistent treatment protocols. A Cochrane review concluded that the available evidence is insufficient to definitively establish acupuncture’s efficacy for Bell’s palsy. While some patients report positive results, more rigorous, large-scale studies are needed to confirm its effectiveness and safety. 

Manual acupuncture techniques, such as twirling, lifting, and thrusting, have shown promise in improving blood flow and facial nerve recovery in severe cases of Bell’s palsy. Studies using laser speckle contrast imaging (LSCI) have demonstrated better outcomes with these methods compared to simple acupuncture. In contrast, electrical stimulation (e-stim) combined with acupuncture is generally not recommended for Bell’s palsy, as traditional acupuncture without e-stim is more commonly studied and practiced for this condition. 

While acupuncture may provide symptom relief for some individuals with Bell’s palsy, its role in treatment remains uncertain due to limited and variable evidence. Manual acupuncture techniques appear to hold more promise than e-stim for this condition. Patients considering acupuncture should consult experienced practitioners and be aware that more robust scientific studies are needed to validate its effectiveness. 

Facial exercises may play a valuable role in managing synkinesis, but their effectiveness relies on proper guidance and implementation. Research has shown that targeted facial exercises, as part of a comprehensive rehabilitation program, can improve facial symmetry and reduce unwanted muscle movements associated with synkinesis. For example, a 2012 study by Dalla Toffola et al. found that both mirror biofeedback exercises and EMG biofeedback-guided exercises significantly improved facial symmetry and reduced synkinesis in patients with facial nerve palsy. 

It’s essential to note, however, that exercises must be performed correctly to avoid worsening synkinesis. Neuromuscular re-education, which focuses on improving muscle coordination and timing rather than strength alone, has been shown to be more effective than generalized exercise routines. With professional supervision and a tailored approach, facial exercises can be an important component of synkinesis management. 

Synkinesis typically develops several months after the onset of facial paralysis, often appearing 3–4 months after the nerve begins to regenerate. In some cases, early signs may emerge as soon as 2–3 months after recovery from complete facial paralysis starts. The condition can continue to evolve following the initial paralysis although most people stablize 12 months. Several factors influence the likelihood of developing synkinesis, including the severity of the nerve damage, the recovery timeline, and the underlying cause of the paralysis. 

Patients with significant nerve damage or delayed recovery (beyond 2–3 months) are at a higher risk of developing synkinesis. It is less common in Bell’s palsy compared to Ramsay Hunt syndrome, which affects up to 30% of patients. The overall incidence of synkinesis among patients with facial paralysis ranges from 9% to 55%, depending on the underlying condition and severity. This variability highlights the complex factors involved in its development and the need for personalized treatment approaches to manage this challenging condition effectively. 

The effectiveness of electrical stimulation (e-stim) or transcutaneous electrical nerve stimulation (TENS) for treating Bell’s palsy remains a topic of debate, with scientific evidence yielding mixed results. While some studies suggest potential benefits, such as reducing muscle atrophy and promoting tissue healing, the overall evidence is inconclusive. Systematic reviews and clinical trials have generally failed to show significant improvements in recovery rates or functional outcomes when compared to conventional therapies. 

Additionally, concerns have been raised about the potential for electrical stimulation, particularly during the acute phase of Bell’s palsy, to contribute to synkinesis—abnormal involuntary facial muscle movements. The most recent Cochrane review on physical therapy for Bell’s palsy emphasized the need for higher-quality studies to make definitive recommendations regarding the use of electrical stimulation. 

Given the limited supporting evidence and the potential risks, including the development of synkinesis, many experts advise caution in using e-stim or TENS for Bell’s palsy, especially during the early stages of the condition. Until more robust data is available, these treatments should be approached carefully and used only under the guidance of a qualified healthcare provider.