Complex plastic surgery restores facial expression

From the Winter 2017 edition of Vanderbilt Medicine Magazine

Patient Kelly Davis with Reuben Bueno Jr., M.D., who performed a complex surgery on her face to restore movement to one side. Photo by John Russell.

When Kelly Davis woke up one morning in April 2016, she told her husband Anthony that she dreamed her face was moving; then she looked in the mirror and saw that it really was.

“I just cried,” said the 46-year-old Morristown, Tennessee, resident. “When I bit down on my teeth, I could see movement on the right side. I was so excited, and my husband was thrilled.”

Davis was diagnosed with Chiari malformation, a structural defect of the brain’s cerebellum, when she was 30, and she’s since had 20 surgeries in New York to relieve pressure and stabilize her brain. In January 2015, she awoke from surgery with the right side of her face paralyzed. Doctors first thought she’d had a stroke but later determined nerve damage was the cause. Davis learned to live with a drooping face, unable to smile or chew on the right side, but when her nose collapsed due to weakening facial muscles, she struggled to breathe. She was referred to Vanderbilt, and Reuben Bueno Jr., M.D., performed her surgery in January 2016.

Davis is one of the first of four Vanderbilt University Medical Center (VUMC) patients who have had cutting-edge facial reanimation surgery performed by Bueno, associate professor and interim chair of the Department of Plastic Surgery.

After receiving his M.D. from Vanderbilt University School of Medicine Bueno completed a fellowship at The Hospital for Sick Children in Toronto, recognized as the world’s leader in facial reanimation surgery, just so he could learn the surgical techniques to restore movement to paralyzed faces. He returned to VUMC in 2014, eager to introduce this specialized surgery in Nashville, his hometown.

There are only a handful of medical centers in the United States that offer this type of facial reanimation surgery, and, thanks to Bueno’s expertise, Vanderbilt is the only facility in the Southeast that offers it for both adults and children.

“We all interact socially by using our faces,” said Bueno. “What patients who have facial paralysis on one side tell me is that, because of the asymmetry, when they’re smiling, they look like they’re scowling or they’re angry. I want to offer reanimation surgery for patients so that in their day-to-day interactions, they can express the normal emotion of being happy or laughing without looking like they are upset.”

Partial or complete facial paralysis can be caused by a stroke, trauma, birth defect or tumor resection. Facial paralysis can also be due to a neurological disorder such as Bell’s palsy, Bueno said.

Less complex surgeries can be done that provide improved appearance at rest but do not restore movement. For patients who have facial paralysis on one side, as Davis did, the more complex surgery performed by Bueno involves relocating and positioning a muscle from the leg to the corner of the mouth, connecting blood vessels from the muscle to the vessels in the face, and connecting the nerve that powers the muscle to a nerve deep in the face.

The nerve used is a nerve branch to the masseter, one of the muscles responsible for chewing. Other muscles and nerves can be used, but Bueno said that in some patients, using this combination of muscle and nerve provides the best reconstruction. The goal is to provide both symmetry of the face at rest and facial movement when smiling.

“The nerve that powers the masseter has three branches, so we’re sacrificing one to bring movement to the paralyzed side, but we’re leaving two behind so the jaw still works fine,” said Bueno. “It’s a long surgery—about eight hours. One of the biggest challenges is that we have to be patient after the surgery because it takes three to four months for that muscle to re-innervate and for the muscle to move. It requires patience from both patients and me.”

Davis’s patience paid off, and on her daughter’s wedding day, she smiled through tears.

“My nose is standing back up, and I can breathe,” Davis said. “When I couldn’t smile, I looked horrible. I acted like it didn’t bother me; I’ve been through a lot worse in my life. The main thing I wanted was to be able to breathe, but I also realized I wanted to smile again, like when my daughter Gabrielle got married. Now, I can, and I owe it all to Dr. Bueno and the good Lord.”