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Stanford Report, October 23, 2002

Medical center surgeon gives child reason, not to mention ability, to smile


While still in the hospital, Chaesuk and Steve Kim noticed something wasn’t quite right with their newborn son. The right side of his face seemed to be paralyzed. He was unable to close his eye completely and could not move his mouth or smile on the right side.

Kim was later diagnosed with Mobius syndrome, a condition that causes varying degrees of facial paralysis. Children with the disorder often have trouble controlling their eyelids and cheek muscles. For Chris, now 10, the paralysis meant he was unable to form a normal smile.

This kind of inability goes largely unnoticed by a small child. However, most parents are quite distressed by the lack of symmetry. But, as he grew, Chris became aware of his inability to smile normally, which his parents said caused emotional strain. "I heard him praying for fixing his face," Steve Kim said.

Prior to surgery and years of therapy, Chris Kim was literally unable to smile. An unusual procedure at the medical center established the nerve and muscle connections he needed to add variety to his expressions. PHOTO: COURTESY OF JAMES CHANG

Hope that Chris would someday smile like a normal boy came when the family met James Chang, MD, associate professor of plastic and hand surgery and program director in plastic surgery at Stanford. Chang is one of the few surgeons in California who performs corrective plastic surgery and microsurgery on children with Mobius syndrome.

Mobius syndrome is a rare genetic disorder characterized by facial paralysis. The paralysis is caused by the absence or underdevelopment of the sixth and seventh cranial nerves. These nerves control eye movements and facial expression. Newborns may exhibit an inability to suckle, excessive drooling, crossed eyes and other physical or motor abnormalities. Most noticeable is an inability to smile.

"In the past, these children may have been diagnosed with mental retardation because of their inability to smile and react with normal facial expressions," Chang explained. But today, an accurate diagnosis, reconstructive microsurgery and several years of focused rehabilitation can give these children a chance at a normal, healthy appearance.

To treat Chris, Chang performed a complex two-stage microsurgery operation, sometimes referred to as the "smile" procedure. Microsurgery involves the reattachment of nerves and blood vessels less than 1 millimeter in diameter.

During the first stage, surgeons removed a section of sensory nerve located at the side of the foot and leg — called the sural nerve — and implanted it in the face. They then attached one end of the graft to the healthy nerve that controls smiling muscles on the unaffected side of the face. They place the length of the graft beneath the nose, running the other end to the cheek bone area of the paralyzed side of the face. This delicate four- to five-hour procedure involved microsurgery to attach the nerve graft to the working nerve in the face.

For the next three to six months, the nerve is allowed to grow and establish connections with the healthy nerve. Then a second eight-hour surgery is performed in which a 5-inch piece of the thigh’s gracilis muscle is removed, implanted in the affected cheek and attached to the implanted sural nerve, facial blood vessels and the corner of the mouth.

To see dramatic results, patients must do daily exercises for several months to train the new nerve and muscle to respond. Eventually, signals from the brain to the healthy nerve excite the sural nerve, which in turn contracts the gracilis muscle on the opposite side of the face. Both sides of the face will then smile simultaneously, creating a nearly perfect happy expression.

Although the technique is over 15 years old, few surgeons perform it. Chang himself credits the regenerative ability of the human body for the stunning results. "Sometimes I can’t believe this stuff works," he said.

Chris Kim, now a fifth-grader at Simonds Elementary in Sunnyvale, underwent the second operation in November 2000 at Stanford Hospital. His father said he has shown strength beyond his years throughout the surgeries and long rehabilitation. "He has a strong will by nature. That’s all I can say."

Steve Kim added that the surgery’s success has meant a boost in Chris’ self-esteem, as he had hoped. "I wanted to give him confidence," said Kim, adding that Chris now smiles a lot. "He’s doing great."

Saving face: Specialized surgery helps patients with facial paralysis (12/3/97