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Whether unconsciously or reflexively, it happens without much thought: the corners of your mouth turn up and you smile, communicating happiness in one of its purest forms.
What seems like a simple movement of the mouth relies on facial muscles working together with networks of nerves that are responding to information from the brain. If that system goes offline, your smile can be lost along with the ability to control your face.
But through a technique pioneered in Toronto, smile reinnervation or smile surgery, is giving adults suffering from facial paralysis new hope on regaining the function of their face.
Anastasia Fernandes, 32, knows how it feels to lose the ability to smile. In late 2015, the then-newlywed was still suffering from constant headaches and facial numbness that she had earlier attributed to the stress of planning a wedding.
With the symptoms getting worse, her family doctor ordered an MRI that came back with serious news: there was a large mass in her brain that was eventually diagnosed as an acoustic neuroma, also known as a vestibular schwannoma, where a tumour grows on the main nerve from the inner ear to the brain.
Anastasia was referred to neurosurgeon Dr. Fred Gentili at Toronto Western Hospital (TW) where the good news was that these types of tumours were benign, but she would need extensive surgery to remove it which would result in her losing the hearing in her right ear.
"I wasn't ready for something like this," recalls Anastasia. "You always feel somewhat untouchable as a person, especially when you're young, and I had never been sick. So it almost didn't register with me that the tumour was benign because it was so hard to be told that I would lose my hearing."
In January 2016, Anastasia was scheduled for surgery to remove the tumour. What had been expected to be an eight-hour procedure ended up taking 14 hours as the mass turned out to be larger than first thought. Although Dr. Gentili and his team made every attempt to save the facial nerve on her right side, it was so stretched by the tumour that it was impossible to remove the tumour without affecting it.
"Unfortunately, with large tumours, there is a significantly higher risk of injury to the facial nerve during surgery," says Dr. Gentili. "Although we make every effort to spare the facial nerve in every patient, in some cases, because of the size of the tumour and its attachment to the nerve, this is not always possible."
The tumour had been successfully removed, but Anastasia had a long road of recovery ahead of her. Now she awoke from surgery with the added challenge of the right side of her face being paralyzed.
"It never crossed my mind that I might lose my facial nerve," she says. "But after the surgery, I couldn't do anything by myself, so I wasn't that focused on it at first."
After three weeks in the hospital, Anastasia was transferred to Bridgepoint Active Healthcare for in-patient rehabilitation. She had lost a lot of mobility and strength on her right side, and went through a fast track program to regain movement and functionality, work on her memory, and help with her speech now that she had lost movement in her mouth.
"There were definitely moments where I didn't feel normal because of the paralysis in my face," she says. "But while I was in rehab, I just wanted to concentrate on getting better, doing one thing at a time. I didn't have the energy to decide what to do with my smile yet."
Once she could walk again and felt confident being on her own and doing things for herself, Anastasia was discharged and her attention returned to the loss of her facial nerve.
'At first, I wasn't at all keen about the idea of more surgery'
"While I was in rehab, I was seeing improvement every day in my ability," she says. "But when that passed, the changes in my face really started to sink in and it just sucked."
Anastasia didn't know what to do. Static facial surgery, where a tendon is transplanted into the face to lift the smile muscle, was an option but would leave her with a permanent smile and no ability to move her face.
However, a friend who was a plastic surgeon knew of a procedure, common among children, that could potentially restore nerve function to her smile. He recommended that she go see Dr. Heather Baltzer, a hand surgeon with the Hand and Upper Extremity Transplant Program at TW, who was one of a few surgeons in Canada who had been mentored to do the procedure on adults.
"At first I wasn't at all keen about the idea of more surgery," says Anastasia. "But I was already feeling self-conscious when I moved my face, when I laughed. I thought this might be my only chance to look normal again."
Dr. Baltzer, who had joined the team at TW the year prior, was in the midst of setting up her busy practice as a hand surgeon and had yet to take on any patients needing smile surgery.
As a resident at SickKids, she had worked with Dr. Ronald Zuker, a pioneer of the smile surgery procedure that is now used around the world, and been fascinated by this technique. Dr. Zuker had been encouraging Dr. Baltzer to start offering the procedure as part of her practice, and meeting Anastasia was the motivation to do so.
"Patients I've met with this condition feel a need to isolate themselves," explains Dr. Baltzer. "They feel self-conscious of their facial asymmetry and reactions of people around them. It can be very discouraging. Many patients do not even know that surgery could be an option to address their paralysis."
"Anastasia and I are around the same age, and I couldn't imagine going through life not being able to smile," she continues. "That was the push I needed to say to myself, 'ok, let's do this.'"
Smile surgery is a delicate process of bringing a patient's face back to life and there are different approaches to doing so.
Nerves are either transplanted from another part of the body to regenerate, growing a millimetre a day – known as a nerve graft. Or, they are borrowed from another function, such as the chewing muscle, and reattached to the smile muscle much like a livewire into a plug, known as a nerve transfer.
In some cases, like Anastasia's, both techniques are used. In certain circumstances, a new muscle must be transplanted from another body part to the face to restore smile in combination with nerve transfers or grafts.
In May 2016, Anastasia was the first patient at TW to undergo smile surgery. A nerve was grafted from her calf muscle and implanted across her face: attached in the smile muscle of the healthy part of her face, threaded across her upper lip and joined to the smile muscle of the paralyzed side of her face with the expectation that it would reinnervate as it grew with each millimetre.
In order to keep the smile muscle on the paralyzed side from atrophying, a nerve was redirected from her bite muscle to the smile muscle to keep it stimulated, a form of babysitting that keeps the muscle alive while the nerve from the graft grows to join it.
In fact, smile surgery needs to take place as soon as possible and within one year after the incident that caused the paralysis since the muscle can atrophy beyond repair if a patient waits too long.
Roughly two months after the surgery, Anastasia began to see movement on the right side of her face. At first, she had to bite down in order to show her smile, but little by little she saw more progress and now smiles without biting down first.
When, one day, her cheek began to twitch, Dr. Baltzer knew the nerve from the graft had regenerated to the paralyzed side of her face. Anastasia continues to practice smiling as well as talking in front of the mirror as she gets used to how her mouth moves and works to strengthen its muscles.
"Appearance in today's society is huge and losing your face as a girl was a big loss, but I feel much stronger as a person," Anastasia says. "If I hadn't had the surgery I would have regretted it and my smile is no longer the everyday problem it was before."
"I don't know if it would have made any more difference to have the surgery earlier than I did," she continues. "But that would definitely be my advice to anyone in a similar situation, to seek this out sooner rather than later."
Dr. Baltzer has since performed the surgery on a few more patients who are extremely happy with the results, and has consultations with a few more. She and Dr. Zuker work as a team to care for adult facial paralysis patients. It's been a nice addition to her practice where the bulk of her cases focus on hands and wrists.
"It might seem that smiles and hands don't have much in common but it's all part of the same tool box of moving nerves around to give back function to critical areas," she says. "It's really gratifying to use my skills to help people this way.
"I have been fortunate for the great mentorship from Dr. Zuker and look forward to carrying on his techniques in Toronto."