Dr. Snyder-Warwick and Dr. Tung performing the microsurgical portion of a facial animation procedure

When Can Surgery Be Performed?

Timing for surgery is dependent upon the individual circumstances. The duration of facial paralysis guides the appropriate treatment. Nerve reconstructions may be performed in a variety of ages, even very young ages. Muscle transplant procedures are typically not performed until age 5 years, due to higher success rates in this age and older.

Free functional muscle transfer with masseteric nerve
Figure A: Free functional muscle transfer with masseteric nerve.
For later reconstructions, facial movement is produced with new muscle and new nerve. A segment of the gracilis muscle from the thigh is positioned in the face to provide smiling motion. The masseteric nerve, normally used in chewing, can power the transferred muscle in a single-stage technique. The scar for this procedure is depicted with the dashed line. Click to enlarge.

What Will the Scars From the Surgery Look Like?

Attempts are made to make the scars as minimally noticeable as possible. The incisions used for the facial procedures are similar to those used for cosmetic facelifts. The incision runs vertically directly in front of the ear and extends into the hairline and slightly below the jawbone (see Figure A). This incision typically heals nicely, eventually resulting in a thin, flat scar.  For procedures requiring the sural nerve for a nerve graft, two or three small (~2.5cm) transverse scars are created on the back of the calf (see Figure B). These incisions also typically heal very well. For muscle transplants, a segment of the gracilis muscle from the inner thigh is used. The scar is a straight line on the inner aspect of the thigh. This scar may become somewhat wider and more raised compared to the other scars.

What Should My Child Expect on the Day of Surgery?

Prior to the day of surgery, we will provide you with a DVD that describes the experience of having surgery at St. Louis Children’s Hospital, so that your child will know what to expect. Your child will meet many people on the day of surgery including nurses, anesthesiologists, surgeons, and other staff. We all make every effort to make your child’s experience as comfortable as possible. If your child has a special toy or blanket that is comforting, we encourage you to bring it along. We encourage your child to ask any questions that he or she may have.

Sural nerve harvest
Figure B: Sural nerve harvest.
The sural nerve is located in the calf and provides sensation (feeling) to the lateral side of the foot. The sural nerve is commonly used as a nerve graft. The nerve is removed via two or three scars on the back of the leg, shown as the dashed lines. The sural nerve is expendable and is not required for walking. Click to enlarge.
What Should Parents Expect on the Day of Surgery?

We 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 we are treating. The anesthesiology team members will introduce themselves, and then the OR nurse will take your child to the operating room. Depending on what kind of procedure is being done, your child will be in the operating room for four to ten hours. Then you will be able to meet your child in recovery and later up in his or her room.

What Should We Expect After Surgery?

There will be some bruising and swelling in the face where the surgery occurred. There will also be some bruising and discomfort where the nerves and muscles are removed, but usually this can be easily treated with pain medication. The bruising and swelling will improve considerably over the first two weeks. Initially, your child will need to keep his or her head elevated and avoid any pressure to the side of the face where the surgery occurred. There may be a mouth guard in place to prevent damage to the transplanted muscle. This mouth guard will be removed before the child leaves the hospital in most cases.

Your child will be able to eat and drink using a soft diet as soon as he or she wants. We encourage walking the day after the operation. Your child will be on special medication to help minimize pain and discomfort.

He or she can expect to stay in the hospital for one week after muscle transplant and less (1-2 nights) for nerve transfer procedures. If you live far away, we will help you make arrangements to stay at a hotel close to the Medical Center for about a week after discharge from the hospital.

The transplanted muscle may show signs of contracting as early as four months after the operation, but this may not occur for as long as nine months and sometimes even longer. Children often report a different sensation in the face once the muscle starts to work. At this point we will teach your child how to perform facial exercises to strengthen the transplanted muscle.