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If your child that has congenital (at birth) or acquired (during birth or after birth) facial paralysis you may have feelings of guilt. There is no reason to feel guilty. Usually there is nothing that could have been done to prevent the facial paralysis.
In children, facial paralysis “just happens.” It is very rare for facial paralysis to be inherited. There are more than 100 known causes of facial paralysis. When we make facial expressions (such as smiling, frowning, and closing our eyes), the brain sends a signal to the muscles of our face through the pathway of the facial nerve (also known as the 7th cranial nerve). When there is a problem with this pathway, facial paralysis is the result. Some of the more common causes are outlined below.
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Congenital facial paralysis
Congenital facial paralysis can occur on one side of the face (unilateral facial paralysis) or both sides of the face (bilateral facial paralysis). Unilateral facial paralysis can be related to conditions such as hemifacial microsomia, in which one half of the face does not develop as fully as the other, sometimes producing less facial motion on the affected side. Goldenhar syndrome is a type of hemifacial microsomia in which other anomalies can be present, frequently involving the eye and the spine.
Bilateral cases often result from Möbius syndrome (also referred to as Moebius syndrome). The exact cause of Möbius syndrome is not known, but it is thought to be related to failure of development of the blood vessels that would normally nourish the facial muscles and nerves. Children with Möbius syndrome are of normal intelligence on average, but because they cannot display emotion as readily as other children they are sometimes wrongly categorized as learning disabled. Möbius syndrome is sometimes associated with Poland syndrome, a congenital deformity of the chest and hand.
Acquired facial paralysis
In some cases, babies delivered with the aid of forceps sustain an injury to the facial nerve. In most cases this injury is temporary and resolves within several months. However, in other cases the paralysis can persist, resulting in a difference in movement between the two sides of the face. In some of these cases surgery may be recommended to improve facial motion. Other forms of trauma can also produce facial paralysis in children, including head injury (concussion), cuts which divide the facial nerve, and damage to the actual muscles that produce motion.
Sometimes the center in the brain that produces facial motion is injured during removal of tumors. In many congenital unilateral cases the actual cause of the paralysis is never found.
Babies may have difficulty feeding initially. Special techniques, many borrowed from our experience treating babies with cleft palate, are used to help in feeding these infants early on (click here for information). Later treatment of pediatric facial paralysis is mainly directed toward improving the ability to smile.
In appropriate cases, reconstructive surgery may be recommended. Such surgery can be performed as early as age five or six.
Some cases of unilateral facial paralysis can be corrected with a procedure known as cross-facial nerve grafting, which involves a nerve graft from the unaffected side to the affected side. This requires harvesting a donor nerve from the patient’s leg (the sural nerve). After nine to twelve months, a donor muscle from the patient's leg (the gracilis muscle) is transplanted into the face and connected to the transplanted nerve.
This procedure is technically very demanding, and it requires the use of microsurgery to connect vessels with sutures (stitches) several times thinner than human hairs.
While all the intricate movements of facial expression cannot be recreated, the ability to smile can almost always be achieved, and the resulting scar is usually barely visible. To harvest the nerve from the leg typically two or three cuts (incisions) that are about an inch (2.5 cm) long are used. These incisions also heal very well and rarely cause problems.
In cases of bilateral facial paralysis, it is not possible to connect nerves from one side of the face to the other, because both sides are affected. In these cases a gracilis muscle from the leg is transplanted to one side at a time, using a nerve that assists with chewing. Usually, the second muscle transplant can be done three months after the first. The facelift-type incision that runs in front of the ear and up into the hairline in the scalp is used. Usually this incision heals very well, leaving a thin flat scar. It is not necessary to harvest nerves from the leg for this procedure.
- The plastic surgery team will meet you in the preoperative area, where our staff will make sure that everything is ready for the procedure. It is routine to double check name badges and the side that will be operated on. The anesthesiology team will introduce themselves, and then the OR nurse will bring your child to the operating room.
- Depending on what kind of procedure is being done, your child will be in the operating room for between four and ten hours. Then you will be able to meet your child in recovery and then up in your room.
- Expect to be in the hospital for five days or more. If you live far away, arrangements can be made for you to stay at a hotel close to the medical center for about a week after discharge from the hospital.
- Your child will be able to eat and drink with a soft diet as soon as he or she wants. Walking the day after the operation is encouraged. Your child will be on special medication to help minimize pain and discomfort. Usually children recover from the operation without difficulty.
- There will be some bruising and discomfort where the nerves and muscles are removed, but usually this can be easily treated with pain medication.
- There will also be some bruising and swelling in the face. This will improve considerably over the first two weeks.
- A mouth guard will usually be in place to prevent damage to the transplanted muscle. This mouth guard will be removed before you leave the hospital in most cases.
- The transplanted muscle may show signs of contracting as early as three months after the operation, but this may not occur for as long as six months and sometimes even longer.
- Your child will be seen back in the plastic surgery clinic, and will be coached on how to do facial exercises to strengthen the transplanted muscle.
- Borschel GH. Facial paralysis. In: Brown DL and Borschel GH (editors-in-chief): The Michigan Manual of Plastic Surgery, Lippincott, Williams and Wilkins, Inc., Lippincott, Williams and Wilkins, Philadelphia, 2004.
- Westin LM, Zuker R. A new classification system for facial paralysis in the clinical setting. J Craniofac Surg. 2003 Sep;14(5):672-9.
- Bae YC, Zuker RM, Manktelow RT, Wade S. A comparison of commissure excursion following gracilis muscle transplantation for facial paralysis using a cross-face nerve graft versus the motor nerve to the masseter nerve. Plast Reconstr Surg. 2006 Jun;117(7):2407-13.