A New Approach to Pediatric Facial Reanimation Evaluation and Treatment

Deborah Howell (Host): Advancing health. Personalizing care. At Memorial Hermann, this is our mission. This podcast shares the science and stories behind those efforts. Today we're interviewing Children’s Memorial Hermann-affiliated physician Dr. Phuong Nguyen, to discuss a new approach to pediatric facial reanimation evaluation and treatment. Dr. Nguyen serves as an Associate Professor of Pediatric Plastic and Craniofacial Surgery at McGovern Medical School at UTHealth Houston and is the Chief of Pediatric Plastic Surgery and Director of Craniofacial Surgery at Children's Memorial Hermann Hospital.

This is Advance, the podcast series from Memorial Hermann. I'm Deborah Howell. Welcome Dr. Nguyen.

 Dr. Phuong Nguyen (Guest): Thank you. It's good to be here.

Host: Lovely to have you. So facial reanimation provides pediatric patients with the opportunity to have their facial nerves treated, reconstructed or rebuilt with muscle and tissue from other muscles in the body. Before we discuss the details of facial reanimation surgery, can you tell us more about what could cause a patient to be considered for facial reanimation treatment?

Dr. Nguyen: Absolutely. Thanks for that question. So, as many of you have all seen in your day to day interactions, there are a number of patients and people who may have one side of their face or even both sides of their face, not function properly. Probably the most common reason for this is something called Bell's palsy, which many people know about. In fact, some celebrities such as George Clooney and Angelina Jolie all had Bell's palsy at one point or another. In that scenario, those patients often get better, about 70%, but 30% of those patients, ultimately have long-term functional problems where the recovery of the facial movement doesn't come back. Now, specifically in children, and for the pediatric population, we also have some kids who are born without the ability to move their face.

And this can be from a variety of reasons. This may be anything from something congenital, such as Moebius syndrome, where both sides of the face usually do not function, versus an issue with an obstetrical problem, such as some compression on the facial nerve, as the baby's being born as it's being compressed in the birth canal, all the way to after birth, things like tumors, things like trauma.

And these can all cause facial nerve dysfunction anywhere from the brain all the way to outside and under the cheek where the facial nerve is. And that's when I get involved, when you have patients who have suffered either an injury, or a reason where their face is no longer able to function.

And as you can imagine, the face is the first thing we see, and it's a fundamental way humans communicate with each other. So, if you can imagine what life is like without having that ability, it can be extremely alarming and, also, have a profound change on your day-to-day life.

Host: Absolutely. I had a friend who in childbirth, contracted Bell's palsy.

Dr. Nguyen: It's very common. And what most people think is the facial nerve comes back, but I'll tell you, it doesn't always come back and that's when it becomes really a major problem for people in their day-to-day life.

Host: So, can you share more about non-surgical treatment options that are available for patients and when you'd recommend non-surgical options to treat palsy and other facial nerve issues?

Dr. Nguyen: Absolutely. I think you have to think about these problems in terms of when did it start and how long has it been? So that means we put it into what's called either the acute versus chronic categories. So, for instance, if you have a Bell's palsy--and this happened suddenly where you had a normal facial function before--that treatment's a little bit different. So, in that scenario, we would normally prescribe steroids within the first 72 hours to decrease inflammation around the facial nerve, to help with the improvement. However, if it's a chronic issue, meaning that it's been over a year, where you've not had any recovery of the facial nerve, then we're in a different category where treatment will likely now be probably more surgical.

The timing is extremely important because that also determines our expectation for recovery. Another somewhat common source of facial nerve palsy is if you've had some type of injury there, whether it be for instance, motor vehicle accident or a blunt type of trauma, where there's been a crush type of injury to the nerve. We know that sometimes that nerve will come back and regenerate. It just takes time. And this is where a lot of watchful waiting really happens. In those scenarios, we have to see if there's any recovery. If there is early recovery, then we're in the clear, and we can just use facial motion exercises. A lot of that is just therapy.

Now, if nothing's coming back and an EMG is done, which is basically, electrical diagnostic test to see if there's any muscle activity or nerve activity shows that it's not coming back, then we got to act fast. We have to have some type of intervention to save the musculature. So without getting into too much detail too quickly here, the timing really makes a big difference on what your options are going to be, or whether you need surgery.

I think the take-home here is if this does happen, the most important thing is to see a facial nerve specialist as soon as possible. So, you have the maximum ability to have different options.

Host: Understood. Now, facial reanimation surgery is a very complicated process for patients to endure. And, of course, its results are highly visible given that you're treating a patient's face. How do you approach evaluating a pediatric patient and what's considered during the evaluation process?

Dr. Nguyen: Well, the first thing I consider again is when did this happen and why did it happen? The second thing I consider is the age of the patient. So, as you can imagine, a two-year-old or a three-year-old who may not be that cognizant of their facial movements, it's going to be very different than an adolescent or a teenager who may be having some significant psychosocial implications from having a facial nerve palsy. The other thing that's very important for that is how are they able to participate in therapy? So, for my patients, my general age cutoff for when is the appropriate time to suggest a surgical intervention would be about 5 years old.

Because by that point, the kids have enough wherewithal to understand what's going on, but also be able to follow directions and participate in their subsequent facial randomization exercise therapy sessions.

Host: Once a patient is deemed a candidate for facial reanimation surgery, what types of surgical procedures are available?

Dr. Nguyen: We really categorize it one of two categories. The first one is static versus dynamic. So static means you create some type of structure so that the face is in a better position, but it doesn't really move. So, this would be more helpful for patients who want a shorter surgery, and just want a kind of a normal resting position. To be perfectly honest, this is more applicable in the adult population, especially the head and neck cancer population that has a lot of other things going on, including radiation. In kids, I rarely, rarely do static procedures because the expectation is we want these kids to have long, fruitful lives and really have a robust, dynamic use of their face.

So, the vast majority of my patients will get a dynamic reconstruction. And that can be anything from using some of their temporal muscles, also known as the temporalis, versus borrowing a muscle from the leg called the Gracilis muscle, where we hook that up to a nerve that normally powers your chewing muscle versus, actually borrowing another nerve from the leg called the sural nerve, where we actually cross wire from the normal working side and bring that nerve from one side of the face, all the way to the other, to power the muscle from the leg. It sounds like a lot. It sounds kind of complicated and it kind of is, and it's a miracle that it works. But the idea is that your brain will send a signal to smile and that triggers this facial nerve from your normal side, and basically supercharges this nerve that we borrowed from the leg. It goes from one side of the face to the other, and then sends that signal to the muscle. Also, from the leg that we now put on the face and says, “Contract, make a movement.” And it does in, just like electricity. It does it in almost a near instantaneous way. And that's how we create a new smile. So, this is essentially a smile surgery.

Host: Yeah. I'm just shaking my head in wonder, just fascinating. And what does the future look like for facial reanimation procedures with UTHealth Houston Surgical Faculty at Children's Memorial Hermann Hospital and what advancements are on the horizon in patient care?

Dr. Nguyen: Well, I think there is so much to be done. We've come a long way, but we have a long way to go. Currently, all these techniques have been developed over the last 30 years with some refinements. Since I've arrived here, we've worked on a few different techniques in terms of what can we offer the patients? So, on one hand for some patients, a regional muscle transfer, may be a better use. That's where we borrow that temporalis muscle with the advantage of being, it's a shorter surgery, it's a quicker recovery. But maybe it's not necessarily the right neural input. All the way to using that muscle from the leg, the Gracilis muscle.

So, what I like to do now is I supercharge that muscle with nerves from both a cross phase nerve graft, as well as that chewing muscle, the masseter muscle, so that you basically get movement much earlier. So, the standard old way was to do two separate operations where we'd bring the nerve up from the leg. That's one operation. Wait nine to 12 months while it grows and then put the muscle from the leg up. And then hook everything up. And from the time of the first surgery, at the time where you actually get a smile, that's a minimum a year and a half to two years. And that's a lot to ask for a kid. So, the way I'm doing it now with the two nerves, I tell them, you can expect to have a smile in three months, and that's going to be one where you're basically biting down to get the smile. And then within nine to 12 months, you're going to get your spontaneous emotional smile. And so, we've compacted that two-year process to now being able to get results within three months.

Host: Just incredible. Of course, the surgery has the potential to be life-changing for kids and can improve more than a patient's appearance. What are some of the differences you noticed pre- and post-surgery in a patient?

Dr. Nguyen: Well, you know, we see a lot of kids in my pediatric plastic surgery clinic who have facial differences. And that comes from a variety of sources, for instance, cleft lip, to facial palsy and things like that, or skull deformities, and kids are resilient, but they also have unique challenges that maybe we as adults don't have.

And that's the process of going through adolescence, as you can imagine. And depending on the age, and as they grow, there can be all these external pressures to look like their peers or be able to interact in that way. So, what I see is a lot of kids come in with their shoulders slumped, not making eye contact, not even having a lot of confidence. And you can, read the writing on the wall. What's their future going to [00:11:00] look like with this type of attitude. I have a special, young patient where she had a vascular tumor that was removed in her brainstem that resulted in the facial palsy.

And we did this operation that I just discussed. She did perfectly well and was able to start smiling within three months. And I saw a huge difference in just her composure, coming in. And to be honest, she came in wearing makeup one day, and smiling and telling these jokes and stories. And I thought, wow, this is a different kid. It was really fun and amazing to watch her transformation.

Host: That is definitely heartwarming. Now, considering how facial reanimation treatment can impact a patient's entire life, as you just indicated, how should primary care providers proceed once palsy or facial nerve issues are suspected or identified?

Dr. Nguyen: I think the first thing to do is A, recognize it, and kind of establish the timing and the scenario of it. And B, calling a facial nerve specialist, giving us a call to our clinic, as soon as you see it, because the clock starts ticking. For instance, if it's a Bell's palsy and even if the patient gets better, it's important to have someone be able to monitor it because if it doesn't get better, timing is of the essence.

One thing we didn't talk about, are what are some of the maneuvers between doing the big facial smile operations, versus just watching. And there are other kinds of adjunct things such as therapy, such as using Botox for the other side of the face. So, to make symmetry or even what's called a babysitter nerve where we borrow a nerve that normally powers to the tongue to keep the muscles alive, so they don't atrophy. So, these are some of the things that are part of the algorithm, but, again, you have to have the right timing and have someone who recognizes it. So, my advice would be if you have any patients who come in with this, regardless of whether it just happened, or if this is a long-standing problem, we would love to see those patients as early as possible.

Host: Which brings me to my final question, Dr. Nguyen, how can you receive referrals?

Dr. Nguyen: So, the easiest thing to do is give our pediatric plastic surgery clinic a call. That number is 832-325-7234. Again, that's 832-325-7234, and we will be happy to accommodate you. Certainly, you can reach out to me on my email. I'm listed on the UT website so you can email me directly Phuong.Nguyen@uth.tmc.edu and I'm happy to help advise and point you in the right direction.

Host: Well, thank you, Dr. Nguyen for all your time and the great information today and for giving me yet one more reason to love George Clooney. Who knew?

Dr. Nguyen: Well, you know, he's, who knew, he's yeah, he's such a vulnerable guy. So, you know, but, you know, I think it makes it slightly more relatable that we see that this can happen to anyone.

Host: Absolutely. And to learn more, you can visit Memorialhermann.org. That's Memorial Hermann, H-E-R-M-A-N-N.org. And if you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been Advance, the podcast series from Memorial Hermann. I'm Deborah Howell. Stay well.