The face is the central focal point of human interaction, and facial appearance is often the foundation for development of self-esteem. The Center for Facial Paralysis and Asymmetry at Cohen Children’s specializes in facial reconstructions – from minor to highly complex cases.
The face is composed of multi-laminar structures that may require reconstructive restoration. These include facial bones, muscles, soft tissue and skin. The surgical experts at the Center for Facial Paralysis and Asymmetry provide consultations to determine the cause of the problem and then describe the deficiencies that need to be addressed. We use the latest technology in 3D imaging and modeling to restore your child’s natural appearance.
At the Center for Facial Paralysis and Asymmetry, we provide advanced treatment for children with a variety of conditions affecting the appearance of the face, including:
Facial asymmetry can be the result of either a soft tissue volume deficiency or undergrowth of the underlying facial skeleton. A 3D CT scan is frequently obtained to better understand the pathology. Deficiencies in the facial skeleton can be corrected using bone grafts, cements and custom designed patient-specific implants. In addition, we use distraction osteogenesis when necessary to create new bone and length in the affected area.
Linear scleroderma and lupus
Linear scleroderma and lupus are autoimmune disorders that often have soft tissue atrophy as a result of damage to the facial subcutaneous tissue. The immune cells attack the subcutaneous fat of the face, creating a gaunt-like, hollowed out appearance.
Treatment typically involves a combination of medical and surgical therapy. We work in conjunction with our pediatric rheumatologists who can mediate the immune system with the latest in medication therapy. The soft tissue can be restored by transplanting fat from other parts of the body, either as a fat injection technique or as a flap-based technique. Multiple operations are often required to achieve optimal results. Interestingly, fat transferred from other areas does not tend to melt away, as a result of the autoimmune processes. Stem cells in the fat may exert a regenerative effect on the facial structures and is the subject of our ongoing research.
Parry Romberg disease
Parry Romberg disease involves an autoimmune response where the subcutaneous fat of the face wastes away, leaving significant contour defects. It is most common in young females, ages 5 to 15 years. The damage can range from mild to severe. Treatment strategies are developed in conjunction with a rheumatologist and may involve fat grafting and tissue transfer techniques to reconstruct the normal facial contour.
Bell’s palsy and Moebius syndrome
Bell’s palsy is a form of facial paralysis related to dysfunction of the facial nerve. Most cases are one-sided and the source is often unknown. It may be associated with Lyme disease, as well as with the herpes simplex virus.
In the initial consultation, the degree of facial paralysis is first described. The facial nerve has five branches, which innervate specific muscle groups. Each component must be assessed and addressed to completely restore natural appearance.
The facial nerve (temporal branch) powers the frontalis muscle, which is responsible for raising the eyebrow. Paralysis can lead to a drooping brow which may obstruct your vision. Treatment is aimed a static correction, where the eyebrow can be lifted and fixated in a higher position thereby relieving the obstruction and improving the symmetry at rest.
The facial nerve is responsible for closing the eyelid via the orbicularis oculi muscles. A different nerve maintains an open eyelid and balance is important in eyelid function. This is important for maintaining hydration to the eye itself and preventing corneal injury.
Many patients naturally have what’s known as the Bells reflex where the eyeball rotates up when we sleep, which protects the cornea in the event the eyelids cannot close. An exposed cornea can lead to blindness and a surgery aimed at protecting it is of utmost importance. A gold or platinum weight can be placed on the upper eyelid to help gravity assist in closing the eye when needed. This relatively simple operation can be performed as an outpatient or in the office setting.
Weakened tone of the lower eyelid muscles can lead to a droopy lower eyelid and increased exposure of the white part of the eye (sclera). Treatment is aimed at raising and tightening the lower lid so that there is less exposure of the eye. We accomplish this using midface lifting with orbital rim anchoring, as well as canthoplasty techniques.
Lip and cheek animation
Facial expression is the key to social interaction, and the ability to smile and show emotion is what allows us to form healthy bonds. Facial paralysis can cause severe asymmetry, particularly upon smiling. Restoration of dynamic movement may require both nerve and muscle transfers.
Nerve grafts are obtained from a sensory nerve from the lower leg which can be approximated to the facial motor nerve on the unaffected side. We then can connect the newly “powered” nerve to the abnormal side and provide the electricity needed to move the previous “unpowered” muscles. Nerves regenerate at the rate of 1 millimeter per day, and several months may be required to see results.
When the muscles are without “power” for more than one year they often wither away and atrophy. New muscle must be placed to allow for dynamic function. The gracilis muscle from the thigh is often transferred to the face to restore the ability to smile in lieu of the dysfunctional facial muscles. This is often done six to nine months after the initial nerve graft to allow for nerve regeneration.
The facial nerve is responsible for moving the lower lip down during animation and paralysis often resembles a stroke-like appearance. Treatment is aimed at decreasing function of the normal lower lip using either surgical techniques aimed at removing the muscle or decreasing the function of the nerve branch.
In addition, Botulinum toxin (Botox) can be injected in the office to improve symmetry, however the technique must be repeated every six months.
Congenital (at birth) facial nerve paralysis can affect both sides of the face, leading to severe disfigurement. Treatment is similar to our traditional techniques for facial paralysis except a different “power source” is needed to restore dynamic facial motion. Nerve grafts can be approximated to the trigeminal nerve (masseteric branch, V3) to achieve similar results.