Surgery 'Reanimates' smile in patients with facial paralysis

Dr. Kalpesh T. Vakharia and colleagues of Harvard Medical School report good results with "smile reanimation" in NF2 patients with facial nerve paralysis. They hope their study will help remind doctors to include facial rehabilitation in their treatment plan for patients with NF2.

Good Results with Gracilis Muscle Flap for 'Smile Reanimation' Neurofibromatosis type 2 is an inherited condition that causes patients to develop noncancerous tumors. Tumors typically occur along the auditory nerve, with the potential to cause hearing loss. When the facial nerve is affected -- by either tumors or surgery to remove them -- facial paralysis commonly results.

In addition to functional problems (such as problems with speech and eating or closing the eye), facial paralysis is a disfiguring condition that takes away facial expressiveness -- including the ability to smile. "Despite the significant impact of facial paralysis on these patients, little attention has been given to the treatment of this in patients with NF2," according to Dr Vakharia and coauthors.

They report their experience with a muscle and nerve transfer technique for restoring facial motion in five patients with NF2 and facial paralysis. All patients had severe paralysis of one side of the face, with drooping and lack of motion at the corner of the mouth (oral commissure) on the paralyzed side. The patients were three men and two women, aged 12 to 50 years; most had facial paralysis as a complication of previous surgery.

To restore facial motion, surgeons transplanted a small flap of muscle from the inner thigh -- the gracilis muscle -- to the face. The gracilis muscle flap, including associated nerve and blood vessels, was used to replace the damaged area causing facial paralysis. Patients received physical therapy during the recovery period after surgery.

The gracilis flap procedure was successful in restoring the patients' ability to smile. Sophisticated geometrical measurements found a significant increase in the ability to lift the oral commissure on the paralyzed side. Just a few millimeters meant the difference between no movement and a natural-looking smile.

"When questioned about their impressions of their faces, the patients uniformly expressed a dramatic improvement in their ability to express happiness nonverbally," the researchers write. Patients also had significant improvement in scores on a quality of life questionnaire.

Some patients said that the procedure restored the ability to smile spontaneously. That's a potentially important advantage, because while other procedures can restore facial motion, the patient has to make a conscious effort to smile.

Although the study is small, it shows that the gracilis muscle flap is an effective treatment for the facial paralysis in patients with NF2, Dr Vakharia and coauthors believe. They remind all professionals involved in the care of patients with this "devastating complication" to incorporate some type of facial rehabilitation therapy into their treatment plan.