Surgical skill brings back a smile: Celia Hall reports on a plastic surgery technique used to cure a facial deformity in children
Wednesday 07 July 1993
Clare, from Southend, Essex, was born with facial palsy, a condition that affects about two babies in every 1,000. She was unable to move the left side of her face.
While most recover, about 10 per cent, or 50 babies a year, do not and surgery is needed to correct the severe facial deformity, an ugly grimace, that results whenever they try to smile.
Her mother, Linda Mendham said the paralysis was spotted by the midwife. 'She saw immediately that something was wrong. The baby's face did not move on one side,' she said.
The cause of the condition is unknown but it is not thought to be connected with a forceps delivery or damage during labour. Clare had a normal birth. In February, she had the second of two operations which enabled her to smile.
Mr Douglas Harrison, consultant plastic surgeon at Mount Vernon Hospital in Northwood, west London, who has conducted more than 100 operations - 52 on children - is presenting his findings to the British Association of Plastic Surgeons' summer meeting in Oxford this week.
At a briefing in London, he said: 'Facial palsy is very distressing. These people will do anything not to smile because as soon as they show emotion they produce an ugly deformity of the face.'
The surgery is in two parts. First, in a two-hour operation, a 20cm length of nerve tubing is removed from the leg and grafted on to the seventh cranial nerve on the good side of the face.
Mr Harrison described the seventh nerve as a 'goose's foot' which runs down the side of the face beside the ear with offshoots spreading along the cheek, jaw and forehead. The grafted tubing is taken under the skin below the nose across the paralysed cheek to the other side of the face.
Nothing more is done for about six months while axons, or nerve fibres, grow through the grafted nerve. After this, Mr Harrison said they can test that the new nerve is functioning by stimulating it. If it is working, the patient will have a sensation in the functioning cheek.
In the second operation which takes four to six hours a small, but entire muscle called the pectoralis minor is removed from the chest, complete with its own nerves and blood vessels. This is transplanted into the immobile side of the face and connected to the newly grown nerve and to the arteries of the face.
Mr Harrison said that the chest muscle they used had little use and the patients did not miss it. Removing leg nerve caused some loss of sensation but had no other effect.
'We usually like to do this operation at about the age of five, before children start school, because that is the age when they start to be teased,' he said.
'The majority of affected babies can be successfully treated during childhood using this technique. Parents and obstetricians should be reassured that in most cases no blame for the baby's permanent facial paralysis should be attached to the management of the birth.'
He will tell the meeting that in the 52 children they have operated on they could find no links with complications during delivery. 'We conclude that congenital facial palsy is related, rather, to a malformation of the facial nerve or muscle during development of the foetus delivery.' Other studies suggest that the nerve itself is not malformed and they are now looking at the muscle for an explanation.
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