Correcting Facial Paralysis

The affected side of the face sags, the eyebrow droops and the mouth hangs open. The victim of facial paralysis, which results from damage to facial nerves by injury or surgery, often finds it difficult to eat or speak and impossible to close one eye. Worse, he loses the ability to communicate by facial expression, so that an attempt to smile may result in a terrifying grimace, an effort at laughter in the appearance of intense suffering. For many years, facial paralysis has been uncorrectable. Lately, however, surgeons have been experiencing success with several new operations.

The most basic of these techniques involves pulling the face into shape with an internal sling made of fascia, the fibrous tissue that separates and encloses the muscles of the body. Fascial slings do not restore normal muscle control, but by supporting sagging face muscles, they help to bring a certain symmetry to the face at rest.

More satisfactory results are being obtained by muscle transposition. In an operation developed by Dr. Leonard Ru bin of Hempstead, N.Y., the temporalis muscle, which runs from the temple to the jawbone, is split into three sections. These are then separated and connected to the patient's eye, mouth and cheek. After considerable practice before a mirror, a patient can learn to use the transposed muscle to control winking or smiling. The operation returns a near-normal appearance to the face at rest.

The most effective and promising operations, now being performed by an increasing number of surgeons, actually repair the damaged facial nerve. Three techniques have been developed. One simply rejoins the ends of the severed nerve by means of sutures, much as surgeons rejoin damaged arteries or torn muscle tissues. Another, the nerve crossover, requires the use of an undamaged nerve--usually the hypoglossal nerve that controls tongue movement--to innervate facial muscles as well. The third and most difficult procedure is the autogenous nerve graft: surgeons remove a piece of nerve fiber from elsewhere in the patient's body and use it to replace the section of facial nerve cut away in tumor surgery or damaged by injury.

Complex Procedures. Nerve surgery is frustratingly complex. Many nerve fibers are finer than sewing thread, have branchings that are difficult to locate and even harder to suture. The nerve fiber used in an autogenous graft is rarely more than two millimeters wide. Surgeons use a ten-power microscope, hair-thin sutures and exceedingly delicate instruments. The microscope magnifies the nerve enough to make it look as large as a piece of string.

There are complications. The nerves are the body's communication system, carrying messages from the brain to the muscles, and any damage, no matter how well repaired, tends to slow down transmission of nerve impulses. To guard against the formation of scars that could impede the impulses, surgeons wrap the freshly sutured ends with fine Silastic tubing, a procedure not unlike wrapping a hair with plastic film.

Encouraging Results. Because unused muscles quickly deteriorate, nerve repairs should be carried out within a year of the damage, otherwise the operation will do little good. Thus immediately after removal of the parotid gland, site of the commonest form of facial tumor, surgeons now repair the adjacent facial nerve, which is sometimes damaged during the operation. In most cases, this prevents loss of facial mobility.

Facial nerve surgery is already remarkably effective. Dr. John Conley, a Manhattan head and neck surgeon, reports a 70%-to-80% success rate for operations carried out within a year of the original nerve damage.

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