I read this article this morning and didn't see this posted anywhere else:
Smile surgeons bring expression backhttp://www.theglobeandmail.com/servlet/story/RTGAM.20081111.wlsurgery11/BNStory/specialScienceandHealth/homeSix-year-old Francis Kendall is smiling for the first time in his life.
The boy practises in the mirror with his father Adam, an aerospace machinist, at his home in Aldergrove, B.C. The droopy left corner of Francis's mouth now lifts to eat, speak and smile, right on time for Grade 1.
Francis was born with Moebius syndrome, a rare disorder that in the past would have paralyzed his face for life. In March, he flew to Toronto's Hospital for Sick Children for "facial reanimation" surgery by plastic surgeon Ronald Zuker.
Dr. Zuker is at the helm of what his peers now call the "Toronto innovation," a procedure that involves retraining masseter nerves - normally used to chew - to smile. The advance has been picked up by doctors all over North America, many of whom attended a massive plastic surgery conference in Chicago last week.
Dr. Zuker has performed "smile surgery" on hundreds of patients. Years later, they send him smiling graduation and wedding photos.
"Before the age of microsurgery and before the procedures that we developed, for a surgeon it was an insolvable problem," Dr. Zuker said.
"The impact on people's lives was a bit unrecognized and not appreciated from a surgical perspective. We're able to appreciate what that smile really means to them."
Francis's face came alive after nearly 10 hours of surgery and 10 weeks of recuperation. The boy, who is also autistic, will visit Dr. Zuker again for treatment on the right side of his face in February.
Aside from improvements in Francis's eating, the procedure will probably change his entire social experience.
"People think maybe he's staring or glaring at them because of the blank look and inability to do anything else to signify that there's no ill will or that he's actually happy," Mr. Kendall said.
Moebius syndrome, as well as Bell's palsy, brain tumours, trauma and stroke, can erase expression from people's faces. The results are socially alienating, and can devastate a person's self-image because others tend to misinterpret an unsmiling countenance as a disengaged personality and lack of intelligence.
"They're often looked at as being uninterested in what's going on, or not with, or out to lunch, not engaged, and it's sad because it's just the opposite," said Dr. Zuker, adding that sometimes nerve sparks in the lower lip make Moebius patients look as though they're grimacing.
"People think of you as being standoffish, self-important or just rude," says Anna Pileggi, executive director of AboutFace International, an organization for people with congenital birth defects such as cleft lip and palate and Moebius, as well as port wine stains and disfigurements caused by tumours, burns, trauma and stroke.
Through counselling, peer networking, youth camps and parent support groups, AboutFace helps people deal with the psychosocial impact of their conditions. (The group's celebrity spokesperson is KISS front man Paul Stanley, who was born with microtia, a congenital deformity of the ear.) Ms. Pileggi says that historically, literature vilified characters by giving them facial deformities and that those outlooks have bled into modern society.
"To demonstrate deviation of behaviour and evil, we usually characterize with facial disfigurements: warts, scars. That is what we've all grown up with. Our first line of thinking is: 'Who is that? Why did that happen?' And often [our interpretation is] negative."
Ms. Pileggi said some of the people she meets opt out of surgery because they are "afraid of the unknown." AboutFace teaches people who cannot communicate with their faces to develop presence by enhancing their body language, touching others during a conversation and improving their posture.
Jeffrey Marcus, a surgical director at North Carolina's Duke Children's Hospital & Health Center,performs a two-step operation on those who can smile on only one side of their face.
Nerves from the calf are attached to the working nerves in the face. After this extension becomes active, doctors graft and attach a belt-like strap of gracilis muscle from the inner thigh onto the face under the skin: the muscles lift the corner of the mouth up into a smile.
For patients who cannot smile on either side of their face, facial reanimation surgery normally takes six hours, is no more invasive "than a facelift" and typically sees patients smiling within six months, says Dr. Marcus, who patterned Duke University's facial nerve program after Sick Kids's research and presented his results at the conference last week.
During the operation, surgeons graft gracilis nerves and muscles from the ear to the corner of the mouth where the smile would naturally appear. They then link the tissues to masseter nerves in the jaw: The nerve becomes an electrical cord and the muscle serves as the motor that powers the smile. Each side must be corrected, so the operation is often done in two phases. Dr. Marcus said that patients who undergo the procedure have to retrain their brains so that when they want to smile, they clench their jaw instead.
"You have to crosswire your brain a bit. You have to train your brain that when you want to smile, you have to think about biting," said Dr. Marcus, adding that eventually it becomes automatic.
"It didn't take long before the children learned very, very quickly to smile without moving their jaw," Dr. Zuker said. "That was a very, very pleasant surprise to us."
Dr. Zuker is now using MRI scans to study this ability to use the chewing mechanism for smiling. The ability is called cortical plasticity: "It's the concept that the brain is very pliable."
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Facial reanimation
Some people cannot smile, including those who have suffered trauma, stroke and brain tumours, as well as those with conditions such as Moebius syndrome and Bell's palsy. "Smile surgeons" - some of the pioneers Canadian - are now using microsurgery to reanimate patients' faces with muscle and nerve grafts from their legs. Here is an example of an operation for people with nerves damaged on one side of the face.
ANATOMY
Measurement for length of gracilis muscle needed for surgery.
The sural nerve is located in the middle of the calf between the two heads of the gastrocnemius muscles.
THE PROBLEM
Malfunctioning nerves aren't able to contract muscles, paralyzing the face. The eyes and mouth may droop, and the patient is unable to smile.
THE SURGERY
First Surgery
Doctors graft the sural nerve (from the calf) to the patient's functioning facial nerve through incisions in the mouth and around the ear. It takes six to 12 months for the nerve extension to become active.
Second operation
(6-12 months later)
Through incisions in the mouth and cheek, doctors attach a length of gracilis muscle between the ear and corner of the mouth. The muscle is powered by attaching its own nerve to the implanted nerve extension. When the muscle contracts, it pulls the corner of the mouth up into a smile.
THE GLOBE AND MAIL 8 SOURCE: FACIAL PARALYSIS AND FACIAL REANIMATION - JEFFREY R. MARCUS/GREGORY H. BORSCHEL/RONALD M. ZUKER
