Plastic Surgery: Facing Up

When many of us think of plastic surgery, what generally comes to mind are face-lifts, tummy tucks and nose jobs. While those procedures enhance the lives of millions of Americans, they’re only a subset of the medical care provided by plastic surgeons.

Dr. Kalpesh Vakharia estimates that he spends about 60 percent of his time treating patients with medical and surgical disorders of the head and neck, as well as traumatic injuries.

Dr. Vakharia — who is the associate professor of otorhinolaryngology-head & neck surgery, chief of facial plastic and reconstructive surgery, and director of the Facial Nerve Center at the University of Maryland School of Medicine — spoke recently with Jmore about his institution’s innovative treatment options for patients with facial paralysis.

What exactly is facial paralysis? The facial nerve controls the muscles of facial expression and allows for voluntary and involuntary movement of the facial muscles. Facial paralysis is where patients have trouble moving the muscles [that enable] facial expression. Typically, only one side of the face is affected. There are numerous causes of facial paralysis. It can affect a patient’s appearance, function and quality of life.

What causes it? It can be caused by a stroke, infections such as Lyme disease or the herpes simplex virus, tumors or cancer. Or it can be caused by trauma such as a gunshot or knife wound. … Falls or automobile accidents that cause head injuries can also cause facial paralysis. It can also be iatrogenic. [In other words,] if in the process of excising something like a tumor, a facial nerve is severed.

How does facial paralysis impact patients? Facial paralysis can have a significant impact on patients, physically and mentally. Patients will be unable to close and protect their eyes, may have limited vision due to a droopy eyebrow, and have ocular irritation and tearing. [They may also have] droopy lower eyelids, a droopy face, difficulty with speech, drooling, inability to smile, facial asymmetry and be limited in their ability to communicate verbally and non-verbally.

This has a huge psychological impact on patients. They may suffer from depression, feel isolated and have a diminished quality of life.

How soon after paralysis should a patient see a plastic surgeon? As soon as possible. Often, after a patient’s face becomes paralyzed, the patient is referred to a neurologist. That’s good, but [the neurologist] may not have his or her pulse on the latest treatments for facial paralysis. When patients see doctors who don’t have expertise treating facial paralysis, they are often told, ‘There’s nothing we can do.’ In fact, there are lots of options.

Such as? Options depend on what caused the paralysis and other factors. But often, we use a combination of treatments. Medical treatment for paralysis usually includes steroids and antivirals to minimize inflammation. Botox, a medication that is injected to paralyze muscles, is sometimes used, especially with Bell’s palsy patients who recover but may have abnormal spasms or twitching. Botox can calm that down. We can also weaken the normal side of the face to make the other side look more symmetric.

Sometimes, we put dermal fillers into the lower lip. This may help patients to close their lips which can prevent drooling.

There are also surgeries. The type of surgery depends on the cause of the paralysis and how long the patient has been paralyzed. I do a lot of masseteric to facial nerve transfers. These are usually done about 9-12 months after paralysis occurs or earlier, depending on what causes the paralysis. We take a branch of the facial nerve which controls the ability to smile and connect it to the masseter nerve [in the cheek] which controls one of the muscles used for chewing. If everything works as expected, in about four or five months the patient can smile when she bites down.

I may also send patients to physical therapy to help reteach them to smile.

With patients who have been paralyzed for two years or more, I can do a gracilis muscle transplant. This is when you transplant the gracilis muscle [in the inner thigh], to the face and innervate [supply nerves to] either the masseteric nerve or a facial nerve branch from the opposite side of the face. This surgery will allow the patient to smile again.

Sometimes patients can have improved facial aesthetics and function from a little eyelid lift, a facelift or eyebrow lift to make things more symmetrical.

What’s most gratifying about your work? I form long-term relationships with my patients and get to know them well. Nerve surgeries require a lot of patience. Waiting for nerves to grow takes time. We do the surgeries and then wait and see. When people don’t recover well, you figure out another plan.

It’s also gratifying to help patients function better. I try to tailor treatment to the patient’s needs.