For children who have been impacted by facial paralysis (palsy) caused by nerve damage, tumor, stroke, infection, trauma or other conditions such as Moebius syndrome, Children’s Memorial Hermann Hospital offers innovative facial reanimation procedures. Through facial reanimation surgeries, patients regain the use of their facial muscles for functions such as smiling and chewing, for improved speech and improved facial symmetry to remedy drooping.
The majority of facial palsies in children are Bell’s palsy, a temporary facial paralysis that results from damage or trauma to the seventh cranial nerve – also called the facial nerve. This nerve runs the length of a narrow canal in the skull, underneath the ear, to muscles on each side of the face. The nerve is contained in a bony shell called the Fallopian canal. Bell’s palsy occurs when the function of this nerve is interrupted, causing messages sent from the brain to the facial muscles not to be carried through, leading to paralysis or facial weakness. In some cases of brain trauma, every branch of the facial nerve may be affected. Some patients may not be able to close their eyes, leading to dry eyes because their corneas are constantly exposed.
Other causes of facial paralysis include nerve damage due to tumors or brain stem damage, severe trauma such as gunshot wounds or knife wounds, or infectious causes such as Lyme disease or ear infections. By and large, the majority of facial palsies (50% to 70%) are caused by Bell’s palsy.
Facial reanimation is a complex, dynamic process that involves a set of lengthy surgical procedures followed by intensive physical, occupational and speech therapy to strengthen the muscles and nerves. The amount of surgery and rehabilitation needed vary from patient to patient. Seeking treatment early is important – as facial paralysis persists, the potential for muscle atrophy (weakness and death) increases.
In some cases, your doctor may transfer nearby muscles, such as the temporalis muscle, by reorienting them into the “smile-line” of your face. Throughout time, you may be able to increase mobility by concentrating on the action. Early after surgery, smiling becomes a voluntary motion, rather than one that is spontaneous; you must elicit the smile by biting down. Over time, the brain is able to reorganize such that you don’t have to bite down to smile.
The bulk of facial reanimation surgeries depend upon a two-stage treatment that involves multiple surgeries, followed by intensive physical, occupational and speech therapy to build strength in facial muscles and nerves.
In the first stage of the surgery, a nerve is taken from your leg and connected to the cranial nerve on the normal, working side of the face and brought underneath the skin above the lip. After 9 to 12 months, the Tinel’s sign test is performed on the nerve to check the extent of its growth. If sensation is present on the affected side of the face, the second stage of the treatment may begin.
In stage two of the surgery, your physician will likely take tissue from the gracilis muscle of your thigh to transplant it to the affected side of your face. This muscle is chosen because tissue can be taken without impacting leg mobility or creating a functional deficit. In addition, it possesses a discrete blood supply and a nerve that causes it to contract.
The muscle is transposed into the paralyzed side of the face and blood vessels are connected through microsurgery. The damaged nerve is then connected into the replaced nerve. The working side of the face sends a signal across this bridge and stimulates the muscle to contract. Because the cranial nerve seven is still used, the smile is spontaneous and, for the most part, natural.
Once the surgery is complete, patients are typically monitored hourly in the ICU for 48 hours after the procedure. This is to ensure continued blood flow to the transposed muscle. Because muscles die without innervation and the blood vessels involved in the surgery are so small, it is important to ensure blood continues flowing to the affected part of the face. After 2 days of hourly monitoring, you will likely be monitored for another few days every 4 hours. Patients usually go home after 4 days in the hospital.
The only downside to this procedure is the length of time from initial consultation to recovery. Patients typically do not see results for 1.5 to 2 years, and the extent of recovery depends on many factors.
In some cases and depending on patient priorities, both stages of the surgery may be performed at the same time. An additional muscle – the masseter or chewing muscle – is tied into the nerve system. This allows the patient to have functional use within 3 months and for the “emotional” muscle movement to develop within 9 to 12 months.
You and your doctor should be on the same page regarding treatment and symptoms, as well as your goals for treatment. You will discuss how paralysis started, how long the symptoms have been present and other factors, including treatment goals and outcomes. In addition, we highly recommend meeting with occupational therapists and speech therapists ahead of surgery to get a head start on targeting muscle groups and understanding the required exercises.
Teenagers, for example, may worry about public shaming and teasing, whereas other parents and children may have concerns about functions such as speech difficulties or problems with chewing or eye movement.
The decision to undergo facial reanimation is complex. It depends on many factors. Because facial reanimation depends on active participation in therapy efforts, it is not considered for many children until they are 5 years old. Facial reanimation is also a treatment for adults, but the decision-making process is different because of factors such as age, life expectancy and desired level of function.
Depending on urgency and other factors, you may consider other options – known as static treatments – versus the more intensive dynamic procedures.
In addition to walking through the procedure with your surgeon and taking time to meet with occupational and speech therapists in advance, ensure your child grasps how important it will be to do the therapy. Facial reanimation is a dynamic, progressive treatment that depends on many factors, and while the two-stage procedure is over 90% effective, the level of effectiveness can vary from patient to patient. It is a long process.
One week after the surgery, your child will undergo a post-operative check, at which time you can expect no motion. At three weeks, swelling will have gone down enough to begin physical therapy. Three months after surgery, you will likely see improved movement (with the temporalis muscle or dual-innovative procedure). At that point, watch for continued growth with muscle movement and facial symmetry. Therapy will likely continue for a year, if not longer; there is expected improvement for up through five years.
Facial paralysis can have both psychological and physical impacts on children, affecting everything from confidence around peers to making it hard to eat or speak. Facial reanimation surgery can alleviate those concerns.
While many cases – sometimes as high as 70% – of facial paralysis from Bell’s palsy can improve on their own, the difference is the extent of that recovery. Facial reanimation surgery offers those patients who need additional assistance an opportunity. It is also important to note that some patients do not require surgery; sometimes less-invasive procedures to balance facial symmetry are all it takes to improve their life.
The collaborative care your child will receive through Memorial Hermann’s network of surgeons, primary care providers and occupational and speech therapists is unmatched in the Houston area. The extensive experience of our team offers a range of treatment options to achieve your goals. To learn more about the facial reanimation procedure, please reach out to our team for more information or to schedule your consultation.
If you have any questions, use the online tool below to help us connect with you. To schedule an appointment, please contact our clinic using the information below.
Texas Cranio-facial Team and Pediatric Plastic Surgery Clinic
6410 Fannin Street, Suite 950
Houston, TX 77030
Plastic & Reconstructive Surgery Clinic: (832) 325-7234
Texas Cranio-facial Team: (713) 500-7302
Vascular Anomalies Team: (832) 325-7234
Office Hours: 8:00 a.m. to 5:00 p.m. (Monday-Friday except major holidays)
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