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
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