Dr. Patrick Byrne, Facial Plastic and Reconstructive Surgeon at the Cleveland Clinic, talks about boosting one girl’s confidence with a groundbreaking procedure to fix her facial paralysis.
Interview conducted by Ivanhoe Broadcast News in 2023.
When did you first meet Nicole?
Byrne: I met Nicole a few years ago. She was about five at the time and she had been born with a unilateral facial paralysis so she couldn’t smile or move her face on one side. At that point she was a little young to undergo surgery, but we started planning for her case at that point.
What causes this paralysis?
Byrne: We’re not exactly sure why some kids are born with this problem, but essentially they just cannot move that one side of their face at all. Some kids are born actually with bilateral facial paralysis, and we take care of those kids too, but that’s even far more rare.
What made Nicole’s diagnosis different than others?
Byrne: Well, first of all, congenital facial paralysis is pretty uncommon. It’s much less than one out of 1,000 live births, so it’s not something that a lot of surgeons encounter frequently. We’ve had traditional techniques to improve the function of the face in kids like this and they’re good techniques, but we’re still searching for a much better solution that can display the full range of human emotion. A solution that can protect the eye and restore the smile. This is a bit of a holy grail that’s been difficult to achieve for many, many decades.
What did you do differently that produced these results?
Byrne: We’ve been working on evolving the technique and essentially most important innovations that we’ve been able to accomplish is creating additional vectors of movement. We refer to it as a multi vector or trivector flab, but really we’ve moved from using one nerve and one piece of muscle, which is how it was done for many years. We’ve slowly but surely learned how to split the muscle into multiple strips and use more than one nerve to drive movement in different areas of the face and enhance that movement. In her case, we actually did something we call now a trivector reanimation procedure.
Was that the first time you’ve ever done that procedure?
Byrne: On a child? Yes, she’s the first child we’ve done. One of the first handful in the world, certainly of any age. The goal was that we would restore a full smile as well as a linked movement around the eyes because what we know is that when we smile, we smile with our eyes as well, and so that’s what we’ve tried to accomplish for her.
Where did you take this nerve from?
Byrne: The nerve was first harvested from her legs and we use something called the sural nerve, which is a sensory nerve. It’s not much of a cost to that harvest that was connected to a functioning facial nerve branch on her other side of her face. Then, we supplement that with redirecting and repurposing one of the nerves that’s used for chewing in the face, it’s called the mass nerve. We were fans of a dual innervation approach. I think it increases the likelihood of success, powers a more meaningful smile, and also allows some spontaneity which is a critical part of looking natural for patients.
How incredible that this is all from Nicole’s body, right?
Byrne: It’s all from her, and the functional muscle is harvested from her leg. It’s called the gracilis muscle. It’s a very thin and suitable muscle to transplant into the face.
Is that found in the inner thigh?
Byrne: Yes, the inner thigh, exactly. It’s a muscle that isn’t really that important for everyday use or even in sports, we really don’t see any problems by removing it from the inner thigh. We then trim, thin, contour, and convert it into multiple different slips by preserving the little arteries and branches of nerves between each one. By doing so we try to recreate something that evokes hopefully a fairly emotional natural smile.
The nerve placement is on the opposite side of the paralysis?
Byrne: The muscle is implanted into the weak side of the face, the paralyzed side. One of the nerves essentially is being taken from the good side. That nerve graft we take from the leg is connected to a totally normal nerve, which we have to sacrifice on the functioning side. Those nerve fibers actually grow all the way across the face from one side to the other so that she doesn’t have to think about smiling, it just naturally occurs. It’s like taking an appliance and plugging it into a functional outlet on the other side of the room because that’s where the power is coming from.
Using the paralyzed side of her mouth, is that a form of therapy? Is it a long process?
Byrne: Yes, one of the things about really young kids that can make it a little challenging is that we are using the facial nerve from the other side. You’d have to learn how to do that. That’s spontaneous. But we’ve learned over the years that to augment the movement of the face, it’s really important to utilize the chewing nerve, and that’s not a natural thing. We don’t normally clench our teeth, for example, when we smile.
Is there a big difference between how an adult positions their mouth when smiling versus children?
Byrne: As adults we sometimes force clench a smile, but with adults we can coach them very easily on how to clench down their teeth. In adults, about 70% of our patients learn how to smile without biting down. It’s pretty amazing how the brain can rewire and learn complex movements that become automatic over time. With kids, depending on the age, that can be very difficult to try to compel them through verbal instructions to do something that isn’t always easy until they reach a certain age. Nicole’s progress has been so amazing, but we did wait until she aged a little more. She’s also a really smart kid so that helped. With kids we typically use play therapy to get them to fire that nerve which is normally designed to chew. In turn, that drives their smile and hopefully will eventually become automatic and subconscious.
How long ago was Nicole’s surgery?
Byrne: It’s been about two years now that since her surgery.
How is she doing today?
Byrne: She’s doing great. In fact, a few months ago on Easter Sunday, I got a nice text from her mom saying how much she loves her emile and she sent and beautiful pictures along with it. She said Nicole loves her smile and isn’t worried about her appearance anymore. She’s playing soccer and thriving in school. She’s doing really well.
For Nicole, a child, to have gone the rest of her life not confident in her smile — what you did is pretty life changing for her.
Byrne: You know, there’s nothing I enjoy more than taking care of congenital facial anomalies and amongst those, it is challenging restoring a smile on someone who is paralyzed.
Well you did it! Now Nicole has a beautiful smile.
Byrne: Yes, she’s a great kid. She looks awesome
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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