Synkinesis

What is Synkinesis?

Overview

Facial synkinesis refers to abnormal regrowth of facial nerve fibers which may result in involuntary (unwanted) contraction of certain muscles during other intended facial movement.

Examples of synkinesis include:

• When you smile, the eye on the affected side may close
• When you smile, your neck muscles tighten
• When you blink, or close your eye, the corner of the mouth on the affected side pulls up
• When you chew your eye closes

Facial synkinesis may occur in anyone who has a history of facial nerve paralysis, but it is most often seen in patients with delayed recovery of facial nerve function (i.e. greater than 2-3 months).

It is less common in Bell’s palsy (10%) and more often seen in patients with Ramsay Hunt Syndrome (30%). Synkinesis may also occur if the facial nerve is harmed or injured following removal of a brain tumor, salivary gland tumor, or as a result of trauma to the head or face.

Synkinesis is not typically isolated to one part of the face and usually affects multiple regions such as the eye, mouth and neck. It affects each patient differently.

Some patients with synkinesis do not seek treatment while others require a multidisciplinary approach that includes a facial plastic surgeon, physical/occupational therapists and/or a speech-language pathologist.

Who is Affected?

Synkinesis can affect anyone who has experienced facial nerve paralysis, regardless of the initial cause. It is most commonly seen in individuals recovering from delayed or incomplete facial nerve recovery, particularly following Bell’s palsy, Ramsay Hunt Syndrome, head or facial trauma, or surgical procedures involving the facial nerve, such as removal of a brain or parotid gland tumor. While both men and women can develop synkinesis, it tends to appear months after initial facial weakness, often when nerve fibers regrow abnormally. The condition can affect people of all ages and may cause significant functional and emotional challenges, especially if it interferes with eye closure, speech, or facial expression.

Synkinesis Symptoms & Causes

Symptoms

Synkinesis occurs after complete facial paralysis has resolved and you start to experience recovery and reinnervation of the affected side of your face. It may take 2-3 months after the recovery is completed and patients will begin to notice the involuntary “linking of movements.” In addition to the unwanted linking of movements, patients may also complain of pain or tenderness in these locations as well, with or without movement. In most cases, synkinesis will not resolve completely and will require continued therapy for the remainder of the patients lifetime.

The types of synkinesis that are most often observed are:

• Oral-ocular: when moving the mouth (eg. To smile, lip pucker, chew) the eye on the affected side will partially/fully close. However, the unaffected eye will remain wide open
• Ocular-oral: when elevating the eyebrows or closing the eyes, the corner of the mouth will raise on the affected side
• Midfacial: at rest or with eye/mouth movement the cheek on the affected side will tighten leading to a deeper crease at the nasolabial fold and pain/discomfort in the cheek area
• Mentalis: when initiating eye or mouth movement, the chin will experience a dimpling on the affected side
• Platysma: when moving the mouth, the neck muscles on the affected side will tighten. This can prevent full smile elevation and pull the corner of the mouth downward

Causes

​​Synkinesis occurs as a result of abnormal regeneration of facial nerve fibers following an episode of facial nerve paralysis. When the facial nerve is damaged—due to viral infection, surgical trauma, tumor removal, or blunt injury—the healing process may lead to misrouting of nerve signals. As a result, fibers that were originally responsible for one function (such as smiling) may unintentionally connect to muscles involved in another function (such as blinking). This creates a “cross-wiring” effect, where voluntary facial movements trigger unintended muscle contractions. Although synkinesis can occur in anyone recovering from facial nerve injury, it is more common in those with delayed or incomplete recovery and may become more noticeable months after initial nerve healing begins.

When to See a Doctor

You should see a doctor if you have experienced facial paralysis and begin to notice involuntary movements, tightness, or facial asymmetry as you recover.

Warning signs that warrant medical attention include:

• Eye closure when smiling or eating
• Facial tightness, pulling, or pain in the cheek, chin, or neck
• Difficulty with eyelid closure or oral movements affecting speech or eating
• Increased facial asymmetry or noticeable facial distortion with expression
• Emotional distress or anxiety related to facial appearance or movement

Early intervention with our facial nerve specialist and multidisciplinary team—including facial plastic surgeons, physical therapists, and speech-language pathologists—can help improve function, reduce discomfort, and prevent worsening of symptoms. If symptoms are affecting your quality of life, seeking care promptly can lead to better long-term outcomes. Contact us at 310-829-8701.

Synkinesis Diagnosis

Synkinesis is a clinical diagnosis, meaning it is identified through a careful history and physical examination by a physician experienced in facial nerve disorders. Because the signs can be subtle or vary in intensity, it’s important to describe the timing, location, and nature of your symptoms in detail.

Physical Examination

Your physician will assess facial symmetry at rest and with movement, looking for patterns of involuntary muscle contractions during voluntary facial expressions, such as smiling, blinking, or puckering.

Symptom Documentation

To enhance accuracy, it is often helpful to document symptoms with digital photographs or video recordings, especially if your symptoms change throughout the day or worsen with fatigue.

Electromyography (EMG)

In some cases, electromyography (EMG) may be used to study muscle activity and identify abnormal nerve signaling. This can help confirm the presence of synkinetic movements and guide treatment planning.

Since synkinesis typically develops months after facial nerve injury or paralysis, early evaluation by a facial nerve specialist is key to monitoring recovery and identifying signs of misdirected nerve regeneration as they arise.

Synkinesis Treatment & Outcomes

Treatment Options

The goal for treating synkinesis is to reduce the unwanted facial movement and to restore balance to the face. Since each patient has a unique type of synkinesis, the treatment of synkinesis will vary from patient to patient. Most, but not all, patients will benefit from a multidisciplinary approach that includes facial therapy by an expert in facial physical/occupational therapy, speech language pathology, and plastic surgery of the face.

There are several excellent methods used to treat facial synkinesis. Below we have listed these treatments from minimally invasive (facial therapy) to invasive surgery (selective neurolysis).

• Facial retraining therapy
• Mindfulness/Meditation
• Acupuncture
• Chemodenervation with botulinum toxin
• Selective neurolysis surgery

Patient Outcomes

​​Outcomes for patients with synkinesis can vary depending on the severity of symptoms, the cause of the original facial nerve injury, and the timing of intervention. While synkinesis typically does not resolve entirely on its own, early diagnosis and a comprehensive treatment plan can lead to meaningful improvements in both function and appearance. Many patients experience reduced tightness, improved facial symmetry, and greater control of facial movements with consistent therapy. In some cases, surgical procedures or targeted Botox® injections can further enhance results when conservative measures are not sufficient. Long-term outcomes are best when patients work closely with a multidisciplinary team to monitor progress and adjust care over time.

Managing Synkinesis

Managing synkinesis involves a personalized, long-term approach to reduce unwanted movements, improve facial function, and enhance quality of life. Key strategies may include:

Regular follow-up with our facial nerve specialist and facial plastic surgeon is important to assess progress and modify treatment as needed. While synkinesis may require ongoing management, many patients achieve significant relief and greater facial control through a combination of therapies.

Meet our Expert Specialists & Surgeons

Amit Kochhar, MD

ENT Surgery, Facial Nerve, Plastic & Reconstructive Surgery

Howard R. Krauss, MD

Neuro-ophthalmology

Alexander M. Solomon, MD

Neuro-ophthalmology

Shanthi Gowrinathan, MD

Psycho-oncology

Experience Compassionate, Expert Care

Through a multidisciplinary approach we care for each patient with a treatment plan tailored to their condition. At the Pacific Facial Disorders Center, our team works together to provide comprehensive diagnosis and definitive treatment options for a wide array of facial nerve disorders and facial pain syndromes. Our doctors and surgeons practice at award winning hospitals throughout Los Angeles.

Facial Nerve Disorders Program Director and otolaryngologist, Dr. Amit Kochhar, has over a decade of experience managing patients with facial paralysis. He treats and is accepting new patients from all over California, Arizona, Nevada, Oregon and Washington.

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