One of the most socially and functionally disruptive
maladies is a facial paralysis. Facial paralysis
usually results from trauma, surgery, or a Bellís
palsy. Problems that result from a facial paralysis
include exposure of the eye which can lead to chronic
irritation, a disfiguring appearance, and drooling.
The duration that the facial paralysis has been
present will help Dr. Lopez determine which procedures
the patient would benefit from. Dr. Lopez
comprehensively treats patients with facial paralysis by
addressing the eye, cheek and area around the mouth.
Patients that have a facial paralysis are unable to
completely close their eye and therefore leave the
cornea exposed to the elements which can cause
irritation, infection and even blindness. Dr. Lopez
performs procedures that include a gold weight to the
upper eyelid and a lower eyelid elevation which narrows
the fissure of the eye and protects the eye from
With time, a patient with a facial paralysis will
experience sagging of the face. To correct this, Dr.
Lopez performs a browlift
and midfacelift which
provides a more natural youthful appearance.
One of the most distressing results from a facial
paralysis is the drooping of the corner of the mouth
which can lead to drooling as well as a disfigured
appearance. Dr. Lopez performs a minimally invasive
temporalis tendon transfer (T3) to correct the asymmetry
of the mouth as well as give motor function to allow for
For patients that have had a facial paralysis for
less than 18 months, a nerve procedure can restore tone
and some muscle movement to the lower third of the
face. Dr. Lopez connects part of the nerve that
innervates the tongue to the facial nerve that no longer
works. This will give tone to the lower muscles of the
face to prevent drooping and possibly restore some motor
When discussing reanimation procedures the best place
to start is by looking at
before and after photos to see just what can be
accomplished. Often times many procedures are combined
to achieve a complete facial reanimation. The most
common combination includes a gold weight for the upper
eyelid blepharoplasty, a lower
eyelid elevation, a browlift,
a midfacelift, and a
minimally invasive T3.
At your initial consultation, Dr. Lopez will evaluate
the bony and soft tissue architecture of your face. An
overall assessment of the face provides the basis for
what one may expect from facial reanimation. Age, along
with the degree of deformity and function are important
factors influencing the outcome of an operation.
As with all facial plastic surgery, a thorough health
assessment and realistic expectations are prerequisites.
Your understanding of procedures and preoperative and
postoperative routines is essential to a successful
At your preoperative
appointment Dr. Lopez will go over the instructions with
you to follow before and after surgery. Preoperative
photographs will be taken and your questions will be
answered. A complete facial reanimation can take about
4-5 hours depending on the underlying structure.
Recovery time from the anesthetic takes about an hour
and most patients are admitted to the hospital for
Please avoid any
aspirin, aspirin-containing products, or
ibuprofen (Advil, Aleve, etc.) for two weeks
prior to and two weeks following your surgery.
See our "Medication
List" for products to avoid prior to
surgery. If you are on any medications that
affect bleeding (such as coumadin or warfarin)
please notify the office immediately.
Please refrain from
tobacco products for six weeks and alcohol for
one week prior and three weeks following
surgery. Along with delayed wound healing,
persistent skin redness and other complications
may persist when tobacco and alcohol are not
Please notify us of
all routine medications and significant health
history. We ask that you remain on your daily
medications unless instructed otherwise. At the
preoperative appointment you will be told which
daily medications to take with just a sip of
water on the morning of surgery.
preoperative appointment you will be given
prescriptions for use following surgery
including an oral antibiotic, antiswelling
medication, antibiotic ointment and pain
medications. Please obtain these prescription
medications before your surgery so you will have
them ready for use when you return home after
We will ask you to
take Arnica, a natural herb that significantly
decreases bruising, before and after surgery. We
will also ask you to take Vitamin C (ascorbic
acid), which helps promote healing, before and
You may not eat or
drink after midnight the evening before the
procedure unless instructed otherwise. You may
brush your teeth. Your procedure will be
cancelled if you do not follow these
Remove all make-up
and nail polish before arriving for your
Someone will need
to drive you home after your surgery and stay
with you that evening. Transportation to the
office for dressing removal the day following
surgery is also required.
When you wake up from surgery you will notice a
soft, bulky head wrap dressing. You will be asked to
come to Dr. Lopez's office the following day after
surgery for dressing removal. You will be asked to
return in five to seven days for suture/clip removal.
- Keep dressing dry and intact the evening
- Following dressing removal the day after
surgery, you will notice little clips in your
hair. We will again instruct you on wound care.
Cleaning the suture with a Q-tip dipped in
hydrogen peroxide and then applying the
antibiotic ointment three times a day is an
essential part of the healing process.
- You will be asked to return to the office
about seven days after surgery for removal of
clips and/or sutures. Because most patients tell
us their forehead is temporarily numb following
a browlift, it is uncommon for patients to
complain of significant pain with clip/suture
Most patients complain of discomfort more than pain.
Use pain medication as directed/as needed. Vicodin
and Percocet contain Tylenol. Do not take additional
Tylenol or acetaminophen while taking Vicodin or
Percocet. Do not drive or drink alcohol while taking
pain medication. Taking pain medication with food
helps minimize nausea sometimes associated with pain
- Start your antibiotic (Keflex) when you
get home and one at bedtime. It is not
uncommon to have a low-grade fever for 24
hours following surgery.
Start swelling medication (Medrol Dosepak)
when you arrive home. Then follow package
directions. Take with food.
- Vitamin C helps promote healing. Take
1000 mg three times a day for one week
- Arnica, a natural herb that
significantly decreases bruising, is used
under the tongue three tabs three times a
day before meals for two weeks.
Advance diet from liquids
to soft food (oatmeal, French toast, yogurt, soup,
pasta) to your regular diet as tolerated. You have no
diet restrictions. Often the anesthesia you received
can make your stomach feel uneasy for the first 24 hours
so avoid large meals.
Rest for entire day after surgery. Sleep with head of
the bed elevated or use two to three pillows for one
week after surgery. Absolutely no bending, lifting or
straining. If you have little children, bend at the
knees or sit on the floor and let them climb on to your
lap. No driving for one week following surgery. Two
weeks off work is recommended.
After 48 hours, you are allowed to shower and gently
wash your hair. Make sure that the hair is dried
thoroughly, but do not use a hair dryer for the first
two weeks. Sensation to the scalp will be diminished
temporarily so you want to avoid causing a burn because
of a hair dryer.
Bruising can be camouflaged at one week
postoperatively with make-up. Always protect your face
from the sun. At this point, a hat and sunglasses are a
good idea. It is ok to apply sunscreen, cosmetics or
facial creams two weeks after surgery. Avoid unprotected
prolonged sun exposure for three months following facial
reanimation surgery to prevent pigmentation of incision
Swelling, bruising and disrupted sleep are very
normal postoperative symptoms and will decrease as the
healing process occurs. Since vision is temporarily
compromised, assistance with daily activities is
Following a facial reanimation procedure, it takes
time for the swelling to subside and for the skin to
heal. Most patients return to work two weeks following
surgery, however three weeks is ideal, depending on the
degree of privacy one is trying to maintain. At three
weeks postoperatively, swelling and bruising may be
apparent to you but not to many of your coworkers and
Final results following a facial reanimation are not
apparent for one full year following surgery. Dr. Lopez
will want to see you 3, 6 and 12 months after the
surgery to ensure that youíre healing as anticipated.
1) When should I get treatment for my facial
One should seek consultation immediately with an ear,
nose and throat doctor following a facial paralysis.
Most commonly the early treatment of a facial paralysis
is with medicine (steroids and antiviral medications)
and protection of the eye. If the nerve was cut during
an operation or from a trauma, surgery may be
indicated. Dr. Lopez will advise patients with a facial
paralysis to have a gold weight placed early as this
will help protect the eye, and the weight can be taken
out if complete nerve function returns.
2) What is the difference between a facial paresis
and a payalysis?
A facial paresis implies that there is some facial nerve
function. The nerve is stimulating some of the facial
muscles to contract. The prognosis for a facial nerve
paresis that is not caused by a tumor is generally very
good. A facial paralysis implies that the nerve is
completely not functioning. There is no movement of
facial muscles. The prognosis for a facial paralysis is
generally not as good.
3) I have a facial paralysis and my face sags. Why?
When the facial nerve is paralyzed there is no nerve
conduction to the facial muscles. When muscles donít
contract they atrophy so that nothing counteracts the
force of gravity. The longer the duration that a facial
paralysis is present; the more severe the sagging of the
4) How does a gold weight help close my eye?
When a patient has a facial paralysis, the eye is unable
to close because the facial nerve is responsible for
innervating the orbicularis oculi muscle that closes the
eye. When the eye is unable to close, the cornea is
left exposed which can lead to irritation, infection and
possibly blindness. Dr. Lopez places a gold weight in
the upper eyelid which help close the eye and protect
5) What treatment does Dr. Lopez use for the lower
Facial paralysis causes the lower eyelid to pull down
because of the lack of muscular tone of the face. Dr.
Lopez performs a lower eyelid recession with placement
of a graft that helps raise the lower eyelid and in
combination with a gold weight in the upper eyelid help
to protect the eye.
6) Why do I need a browlift and/or a midfacelift when
I have facial paralysis?
Facial paralysis causes the facial muscles to atrophy
(decrease in size and strength) such that the side of
the face that is paralyzed over time will settle at a
very noticeable lower position than the normal side,
causing an obvious asymmetry. Dr. Lopez performs a
browlift and/or midfacelift to restore the symmetry that
was there before the paralysis.
7) What is a temporalis tendon transfer?
One of the most disfiguring and functionally disturbing
sequelae of a facial paralysis is the drooping of the
corner of the mouth on the paralyzed side of the face.
Patients often complain of drooling that can be
professionally and socially disruptive. Dr. Lopez
performs a temporalis tendon transfer to elevate the
corner of the mouth and enable the patient to have some
voluntary movement to the corner of the mouth, i.e.
smile. The temporalis tendon transfer was recently
described by a colleague of Dr. Lopez at Johns Hopkins.
The operation involves transferring the tendon of the
temporalis muscle (which is innervated by the trigeminal
nerve and not the facial nerve) to the muscles around
the mouth. A small incision is used in a naturally
occurring crease of the face. By elevating the corner
of the mouth and giving voluntary movement, the
patientís face is more symmetric, and there smile is
more natural appearing.
8) Will I still look like "me" after surgery?
After facial reanimation surgery you will look more like
the former you before the facial paralysis occurred.
9) How much pain will I have?
Most patients who have facial reanimation surgery say
how surprised they are that the pain is less than they
anticipated. Understandably, after any surgical
procedure, some discomfort can be expected. All patients
are provided with prescriptions for pain medication.
Patients sometimes use the prescription medication two
to three days after surgery and then switch to Extra
Strength Tylenol. Patients undergoing a midfacelift will
have some pain on chewing for about 48 hours. It is
uncommon for patients to report unmanageable pain after
10) What if I have a history of bad scars?
If you have pierced ears, the way you healed there is a
good indication of how you will heal from facial plastic
surgery. Scars on the rest of the body typically are not
an indication for how patients heal following facial
plastic surgery. At the time of your consultation, it's
important to show Dr. Lopez any previous scars that are
of concern to you so he can give you a realistic
assessment of your healing potential following facial
11) Will I be awake during surgery?
Patients are asleep during the surgery either with
general anesthesia or using IV sedation (medicine
administered through an IV) and a local anesthetic
(numbing medication administered in the operating room).
Patients do not hear or feel anything and are
comfortable during the operation. Patients wake up very
soon after the surgery is completed. Intravenous
sedation is a type of anesthesia; therefore all patients
must have a responsible adult to stay with them through
the night following surgery. Patients may not drive for
seven days following their procedure and this time may
be longer, depending on the procedure.
12) Do I go home after surgery?
Most facial reanimation procedures are done on an
outpatient basis. Because you will go home after
receiving sedation, you will need to make arrangements
for a responsible adult to drive you home, to stay with
you overnight and to drive you to our office for your
first postoperative appointment. Patients having surgery
must stay in the immediate San Antonio area overnight.
13) Will I bruise and swell afterwards and how long
will it last?
Unfortunately it is impossible to do surgery without
causing swelling. Dr. Lopez does everything possible to
minimize the amount of swelling that occurs. Generally,
postoperative swelling begins to resolve at the end of
the first week. Bruising is extremely variable.
Patients that have a tendency to bruise will generally
bruise for about 10 days. Patients that donít tend to
bruise may have minimal if any bruising. Complete
resolution of bruising and swelling may take two to
three weeks. However, bruises may be camouflaged fairly
easily at seven to ten days with a concealer stick.
14) How long should I stay in San Antonio following
Most patients stay in San Antonio about seven to ten
days following surgery. After that it's ok to fly or
travel long distances.
15) When can I return to work?
Most of Dr. Lopezís patients take about two weeks off of
work. After two weeks, most of the residual bruising and
swelling can easily be camouflaged with make-up.
16) When can I exercise?
Dr. Lopez prefers that aerobic activities be avoided for
two weeks after surgery. In addition, heavy
weightlifting or more strenuous workouts should be
avoided for three weeks postoperatively. It' is
extremely important to avoid bending, lifting or
straining during the early postoperative period as these
activities can increase swelling and delay healing.
FACIAL REANIMATION PREOPERATIVE INSTRUCTIONS
17) Should I do anything before to prepare for
You will have a preoperative appointment with Dr. Lopez
and his staff to go over the preoperative instructions.
18) Why do I need a preoperative appointment?
This is an essential appointment to prepare you for your
upcoming surgery. Dr. Lopez will take preoperative
photographs at the visit as well as go over the
procedure again to ensure that everyone is on the same
page. All questions that you have will be answered on
that visit as well. You will often times be given your
prescriptions on the preoperative visit day. If you are
having a T3, Dr. Lopez will teach you how to do
exercises that you will do before the surgery as well as
after to learn how to make a symmetric smile.
19) What else can I do to do to prepare for surgery?
Dr. Lopez likes to have patients that have well
controlled blood sugar to drink three eight ounce
glasses of pineapple juice for at least one week before
surgery. Pineapple juice can help minimize the
postoperative swelling. Patients that use tobacco will
be asked to stop for six weeks before and six weeks
following surgery. Tobacco has properties that impede
wounds from healing. Dr. Lopez will encourage tobacco
users to not resume smoking at all after surgery; in
fact many of his patients have used the surgery as their
motivation to quit smoking.
20) What about my daily medications before surgery?
In general you will be allowed to take most of your
daily medications. Medications that thin the blood such
as ibuprofen, vitamin E, and herbal supplements need to
be stopped two weeks before surgery. You can continue
to take a multivitamin. Aspirin needs to be stopped
three weeks before surgery. Dr. Lopez will provide a "Medication
List" that reviews all medications and supplements
to avoid prior to surgery.
21) Do I need any special prescriptions before
Dr. Lopez will generally give you a prescription for an
antibiotic, a pain medicine, antibiotic ointment, as
well as an anti-swelling medication. Dr. Lopez does
prefer patients to start Arnica, a natural herbal
substance, the day before surgery in order to minimize
brusing. He also asks you to start taking Vitamin C
FACIAL REANIMATION POSTOPERATIVE INSTRUCTIONS
22) What does it feel like when I wake up from
Most patients report only mild to moderate discomfort,
which may be associated with some numbness, itching,
tightness or a pulling sensation. These postoperative
symptoms subside with time. We will make sure you are
not nauseated or queasy. Our nurses will be right there
with you as you wake up from surgery to give you special
Patients initially experience numbness for the first
six to twelve months following surgery. About two months
after surgery, it is common to have itching or "pins and
needles" as the sensation returns. This itching is
significantly less with an endoscopic browlift than a
traditional browlift. This is actually an important
point because patients who scratch or "itch" their
hairline can thin the hair.
23) Tell me more about the incision.
The head wrap will be removed in the office the day
following surgery. After the head wrap dressing is
removed, you will notice little clips in your hair.
Apply antibiotic ointment to the incision sites three
times a day. You will be asked to return to the office
about seven days from the surgery date for removal of
clips. Because most patients tell us their forehead is
temporarily numb the removal of clips is usually not too
24) What do I look when I wake up from surgery?
Following the procedure, you will have a soft head wrap
around your head and under your chin. This helps
minimize swelling. The head wrap will be removed in the
office the following day. A second dressing will be
gently applied for 48 hours to minimize swelling. You
may have some bruising, however, this typically is more
pronounced 24-48 hours after the procedure.
25) Can I do anything to prevent brusing?
Most patents will have a little bruising. We can
minimize bruising by using Arnica before and after the
procedure. Arnica is a natural "herb" that helps prevent
26) Tell me more about the sutures.
If there are sutures near your ears they will require
some simple care. We will ask you to use a Q-tip to
cleanse them with peroxide once a day and apply an
antibiotic ointment three times a day to keep the
sutures soft. In six to eight days, when the time
arrives for suture removal, sutures that have been
lubricated glide out easily.
27) When can I shower?
You can shower once the second dressing is removed. Make
sure that you pat dry the incisions well after the
shower and apply the antibiotic ointment.
28) What medications do I take following surgery?
Dr. Lopez will ask you to take the following medications
starting the day of surgery:
1- An antibiotic - generally Keflex for one week.
2- Pain medicine - Vicodin or Percocet to take as
3- Antibiotic ointment- to place on the incision sites
at least three times a day.
4- Antiswelling medication- for patients that are not
diabetic a Medrol dosepak will be given.
5- Vitamin C for 1 week following surgery to promote
6- Arnica- place under the tongue three tabs three
times a day before meals for two weeks.
29) When do I begin taking the medications?
Patients take their pain medication as needed. Begin
taking vitamin C one week before surgery. You can begin
taking Arnica the day before surgery. The antibiotic and
swelling medications begin when you arrive home
following surgery. Unless you are notified otherwise,
resume all daily medications when you arrive home from
30) Are there any food to avoid following surgery?
No. Dr. Lopez encourages you to eat a well-balanced
diet. You may notice that saltier foods can cause you
to swell for a longer period of time.
31) When is my first postoperative appointment?
You will be asked to see Dr. Lopez on the first day
following your facial reanimation procedure for removal
of head wrap dressing. You will need someone to drive
you to this appointment.
32) Are there any instructions about my regular daily
Sleep with head of the bed elevated or use two to three
pillows for one week. Facial fullness, headache and
disrupted sleep are very normal postoperative symptoms
and will decrease as the healing process occurs.
Absolutely no bending, lifting or straining. If you have
little children, bend at the knees or sit on the floor
and let them climb on to your lap.
33) How long does the healing take?
As numbness wears off patients experience a
"pins-and-needle" sensation. At about two months
postoperatively patients experience an itchy scalp. It
is important not to scratch as scratching can thin the
hair. These sensations can take up to a year to
dissipate completely. Medications are available to be
used on an as needed basis to ease any significant
sensations. Healing and evaluation of the final result
takes one full year. However, after three months, most
patients have about 90% of their final result.
34) How can I minimize the swelling and brusing?
Most of Dr. Lopezís patients will have a little
bruising. He minimizes bruising by having patients stop
all blood thinners well ahead of surgery as well as
using Arnica before and after the procedure. The cold
packs around the eyes should be used every 20 minutes
while awake after surgery to help prevent swelling and
bruising. The cold packs should be used for the first 72
hours. You do not need to wake up to use the cold packs.
A good nightís sleep is vital to healthy healing.
Patients are also asked to sleep with their head at
least at 45 degrees to minimize the swelling.
35) When will I look normal?
You will be presentable at two to three weeks. You will
look great at six weeks and even better at six months as
things settle and expressions become more natural. At
three weeks you know you are well on the way to recovery
and most patients resume routine activities around two
to three weeks following surgery. Final results are
evaluated at one year.
36) How often do I need to return for postoperative
Dr. Lopez likes to see his patients 3, 6, and 12 months
after the procedure to ensure that the healing is going