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Stanford Report, December 3, 1997

Helping patients with facial paralysis: 12/97

Saving face: Specialized surgery helps patients with facial paralysis

BY TIM STEPHENS

Gary Torresani grew up with a lopsided face, the result of a facial nerve accidentally severed during an ear operation when he was three months old. Surgeons reattached the cut ends of the nerve during a subsequent operation in 1952, when the boy was five years old, but he never regained full movement on the left side of his face.

For most of his life, Torresani simply coped with his impairment, thinking there was nothing more to be done for it. By the mid-1980s, however, the facial paralysis had worsened so much he had a hard time speaking clearly and holding liquids in his mouth. He had also suffered some hearing loss.

In 1987, a doctor referred him to Dr. Richard Goode, a professor of surgery (otolaryngology/head and neck) at Stanford who runs a clinic for treating facial nerve injuries. Goode has now operated on Torresani twice ­ first in 1987 and again in 1997 ­ and the improvements both times were dramatic, said Torresani, who lives in Los Gatos.

"The operation in 1987 profoundly changed the things I could do," he said. "If I had known about this and had been able to do it even five years earlier, it might have drastically changed my life."

Many patients and even physicians do not realize how much can be done to rehabilitate partial or total facial paralysis, according to Goode. Patients with partial paralysis, in particular, may be told that corrective surgery isn't necessary. "They're often told to consider themselves lucky, but the patients don't feel that way ­ they feel deformed, and there are things we can do to correct it," Goode said.

The facial nerve controls all the movements of the face, including the varied nuances of facial expression. An inability to blink can leave the eyes vulnerable to drying out, which can lead to impaired vision. Surgical procedures can give people with partial or total facial paralysis a more normal appearance and can restore important functions such as blinking and smiling.

Bell's palsy, usually caused by a viral infection, is the most common type of facial paralysis. In most cases of Bell's palsy, the paralysis is partial and temporary, but about 15 percent of patients never recover facial function, Goode said.

The facial nerve can also be damaged by trauma, such as a car accident, or by a tumor growing on or near the nerve. Accidental damage from a surgeon's scalpel, as in Torresani's case, is rare but remains a risk in certain types of surgery, Goode said.

The distortion of facial expressions causes some patients to become self-conscious or depressed, Goode said. Torresani had dealt with it all his life. "As a kid I got a lot of teasing and put-downs," he said. As an adult, he faced more subtle forms of discrimination. "If you have a facial impairment or disfigurement, people are going to make judgments about it that sometimes aren't true," Torresani said.

Reconstructive surgeons bring a vast array of techniques to bear on the problem of reanimating a paralyzed face. Depending on the degree of damage, Goode said, he might sew the facial nerve back together, reroute it or patch it with a nerve graft. In some cases, he might connect the facial nerve to an entirely different nerve, such as the one controlling tongue movements, allowing the patient to smile by moving the tongue in a certain way. He can also move portions of muscles and their associated nerves and blood vessels from one site to another.

Other procedures, while not providing active facial motion, serve to improve symmetry and correct the characteristic drooping of the paralyzed face.

In Torresani's case, the facial muscles on the left side had almost completely atrophied by 1987, leaving Goode little to work with. A small band of muscle remained under the eye, and Goode was able to attach Torresani's sagging face and lip to that muscle using a strip of GoreTex.

"That small band of muscle was providing almost all the movement I had on that side of my face," Torresani said. "The operation not only made it look better; it cleared up my diction immediately."

Ten years later, the inevitable effects of aging had caused the left side of his face to droop again. The second operation, in January 1997, was similar to the first but even more extensive. It included restructuring the left side of Torresani's nose, which had collapsed and blocked his breathing through that side.

The movement he has now is slight, but Torresani said his face looks more natural and symmetrical than before. Goode plans to perform one more procedure, a minor adjustment to thin out the left side of the lip. In the meantime, Torresani has begun work toward a master's degree in rehabilitation counseling at San Francisco State University.

Although there have been no major breakthroughs in procedures for facial reconstruction, the techniques have steadily improved over the years, said Goode. "We've upped the bar a little bit in terms of what we consider a success," he said. SR