Background: Bell’s palsy is defined as facial weakness or paralysis due to damage to the facial nerve, also known as the VII cranial nerve. Usually, viral infections due to herpes zoster, influenza, or any upper respiratory tract infections could be a cause. Facial weakness can be accompanied by facial pain or discomfort on the affected side of the face. Facial nerve palsy post-lip fillers is a rare presentation.
Case presentation: A 37-year-old female with no prior comorbidities presented with a 3-day history of left-sided facial pain and heaviness. It was triggered after she had undergone lip fillers. On clinical examination, she had left-sided Bell’s palsy. She was managed with steroids and analgesics.
Conclusion: Facial nerve palsy is an uncommon presentation after lip fillers. There is not enough scientific evidence to show the cause of facial nerve palsy and lip fillers. This case report is to highlight the clinical presentation and management, as well as the possibility of such rare occurrences of post-lip fillers.

Bell’s palsy, Lip fillers, Facial nerve, Case report, Cranial nerve VII.

Bell’s palsy is defined as facial weakness or paralysis due to damage to the facial nerve, also known as the VII cranial nerve. The condition affects 15 to 40 of every 100,000 people annually and recurs in approximately 10% of cases.[1] Usually, viral infections due to Herpes zoster, influenza, or any upper respiratory tract infections could be a cause.[2] Facial weakness can be accompanied by facial pain or discomfort on the affected side of the face. It’s a self-limiting condition that may take weeks to months to recover.[2] Lip fillers are a type of dermal filler that is injected to add volume to the lips. There is an increase in demand for lip augmentation for cosmetic reasons.[3] Lip augmentation procedures have risen nearly 60% since 2000. As it is a minimally invasive procedure, lip injections are getting more popular. According to a 2023 national center for biotechnology information (NCBI) survey, 20.1% of respondents who were between the ages of 18 and 29 and 38.4% and 45.2% of those who were between the ages of 40 and 49, respectively, utilized fillers.[4] Facial nerve palsy post-lip fillers is a rare presentation. Hence, the case highlights the clinical presentation and management.

A 37-year-old female patient with no prior comorbidities presented to the clinic with a 3-day history of facial pain. It was a left-sided pain that was continuous and worsened while chewing. She also complained that the left side of her face was heavy. The pain was not relieved by paracetamol, and hence, she decided to visit the clinic. The patient mentioned that the pain had begun 3 days ago after she underwent lip fillers for lip augmentation. She denied any history of upper respiratory tract symptoms or travel history. She had no similar symptoms before, and also mentioned that her sister underwent the same lip fillers with no post-procedure consequences.

Examinations:

• Vitals are normal.
• Swollen upper and lower lips.
• No dental carries nor gum swelling noted.
• Left facial VII nerve examination revealed – Not able to lift the left eyebrows, not able to close the left eye, not able to lift the left side of the upper lip, and couldn’t blow the left cheek.
• Right-sided facial VII nerve – normal.
• No loss of taste or hearing difficulty. No nasal congestion nor any cough noted.
• No arm weakness nor any slurred speech.

Her overall presentation correlated with House-Brackmann lower motor neuron (LMN) IV weakness. In this regard, the extent of facial nerve palsy is graded using the House-Brackmann classification, stated below, for which there are six grades, depending on clinical presentation.[1,2,5]

I – Normal

II – Mild dysfunction (slight weakness, normal symmetry at rest)

III – Moderate dysfunction (obvious but not disfiguring weakness with synkinesis, normal symmetry at rest), complete eye closure w/ maximal effort, good forehead movement

IV – Moderately severe dysfunction (obvious and disfiguring asymmetry, significant synkinesis), incomplete eye closure, moderate forehead movement

V – Severe dysfunction (barely perceptible motion)

VI – Total paralysis (no movement)

Tablet prednisolone 40 mg once daily for 7 days only. An eye patch should be used at night to cover the left eye, and Hydreye Hyaluronic acid 0.1 % eye drops should be used to prevent dryness. The patient followed up after a week. The lip swelling had markedly reduced. She could lift her left eyebrow and close her eyes, smile without drooping on the left, and blow her cheeks. However, she still had pain on the left side of her face, for which she was prescribed a tablet of ibuprofen 400 mg 4 times daily for 3 days. She was lost to follow-up after that visit.

In the above patient, there is no actual cause behind the sudden facial nerve palsy. She was convinced that the lip filler was the reason behind the nerve palsy. Facial nerve palsy is an unusual presentation after lip fillers. As such, the literature has no evidence of how lip fillers could particularly cause facial nerve palsy. Hence, the diagnosis was Bell’s palsy, a condition that is idiopathic. As per the literature, the commonest cause of facial paralysis is Bell’s palsy, followed by infection, trauma, and iatrogenic causes.[2] The patient presented with facial nerve palsy of both her upper and lower face, therefore demonstrating lower motor neuron palsy. The pathophysiology of Bell’s palsy is unknown but is thought to be due to retrograde epineurial compression edema with ischemia of the facial nerve.[3] The most important factor when considering the differential diagnosis of facial nerve palsy is whether the lesion is Lower Motor Neuron or Upper Motor Neuron. Due to bilateral cortical innervation of the muscles of the upper face, only LMN lesions will result in complete facial paralysis, although this is not always the case. Consequently, the most clinically useful assessment of UMN vs. LMN facial nerve palsy is the raising of the eyebrows, which assesses frontalis and orbicularis oculi.[4] Some diseases that can damage upper motor neurons include cerebrovascular accidents, amyotrophic lateral sclerosis, primary lateral sclerosis, multiple sclerosis, Brown-Sequard syndrome, and vitamin B12 deficiency.[5] Diseases that can damage lower motor neurons include Bell’s palsy, a tumor affecting the facial nerve, middle ear disease, parotid lesion, trauma to the facial nerve, and disseminated sclerosis.[6]

The patient could have developed an immune-mediated reaction to the lip fillers, yet that doesn’t explain the unilateral presentation of the symptoms.[7] One similar case report had been previously reported in the literature, which reports that 20 a 20-year-old woman had left-sided facial nerve palsy post lip augmentation. She was managed with prednisolone 40 mg, and her symptoms resolved after 4 weeks.[8] Another similar clinical presentation after cosmetic filler injection has been reported, which described a patient who experienced bilateral facial nerve weakness after having dermal fillers to treat his nasolabial and marionette lines.[9] Palsy of other cranial nerve branches, in particular oculomotor nerve palsy, has also been reported after the use of dermal fillers. This occurred as a result of ischemia or occlusion of an artery, leading to nerve palsy.[10]

Although it is difficult to understand the actual association between facial nerve palsy and lip fillers, it is important to document such rare cases to create awareness among healthcare professionals of such a possibility. One similar case had been previously reported in the literature.[5] Yet, there is not enough scientific evidence on the association of facial nerve palsy with lip fillers. Hence, further research is required to understand the pathophysiology of such presentations and to figure out whether such a clinical presentation has an association with dermal fillers or is just a mere coincidence.

I sincerely thank Dr. Nida M Khan (Certified Aesthetic and Homeopathic Practitioner) for collaboration, elevating this case report to success.

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Corresponding Author:
Nafi Samira
Department of General Medicine
Abu Dhabi, UAE
Email: ns2435706@gmail.com

Co-Author:
Nida M Khan
Department of Aesthetics and Homeopathy
Maharashtra University of Health Sciences, Maharashtra, India

All authors contributed to the conceptualization, investigation, and data curation by acquiring and critically reviewing the selected articles. They were collectively involved in the writing – original draft preparation, and writing – review & editing to refine the manuscript. Additionally, all authors participated in the supervision of the work, ensuring accuracy and completeness. The final manuscript was approved by all named authors for submission to the journal.

The author declares no conflict of interest.

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https://doi.org/10.63096/medtigo3084115

Nafi S, Nida MK. Bell’s Palsy Following Lip Filler: A Rare Presentation – Association or Coincidence? A Case Report. medtigo J Neurol Psychiatr. 2024;1(1):e3084115. doi:10.63096/medtigo3084115 Crossref