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Plastic and Reconstructive Surgery

History of the Facial Paralysis program at SickKids

The Facial Paralysis Program at Sickkids started with the development of new techniques to address the specific problems of facial paralysis in children. Before microsurgery, the treatment of facial paralysis was based on procedures to position the structures of the face in a more natural location. Although these techniques have a role in the treatment of older patients, its effectiveness is limited in children. Microsurgery has made it possible to transplant nerves and muscles to the face to provide movement. This opened new possibilities for animating the face. These procedures started in the 1970s and evolved through the 1980s. Dr. Ronald Zuker took the opportunity to study in Japan with Professor Harii and observed the idea of transplanting tissue from one part of the body to the other. When he returned to SickKids in 1978 the microsurgery program began. Dr. Zuker and his colleague working with the adult population, Dr. Ralph Manktelow, used the techniques of microsurgery to address the problems facial paralysis. Initially these procedures were done on patients with unilateral facial paralysis, and in the 1980s it became apparent that there was a need to address the problems of bilateral facial paralysis. The procedures evolved and numerous technical refinements were made over the subsequent years. Today microsurgical reconstruction for the child with facial paralysis is considered the standard of care. Facial paralysis can be divided into unilateral cases or those affecting only one side of the face and bilateral cases or those affecting both sides of the face. The approach to management may be quite different but the goals are the same – to effectively animate the face in a spontaneous and symmetrical fashion.

In the unilateral cases the facial nerve from the normal uninvolved side is used with specific branches being connected via nerve grafts and routed to the paralysed side. With facial nerve activity now on the paralyzed side, a new muscle can be transplanted to animate the face. This is revascularized and reinnervated with the previously placed nerve graft. The second procedure is done at least 6 months following the nerve graft procedure. The muscle transplant procedure was so successful that the concept was extended to bilateral facial paralysis situations.

After considerable study of the anatomy, with work in the anatomical laboratory, Dr. Zuker and Dr. Manktelow developed a technique to connect (innervate) the muscles that were being transplanted to the motor nerve to masseter (the muscle of the face used for biting). This was very effective in the bilateral cases and has become their standard of care. The team also refined methods to reduce muscle size and secure fixation for improved outcomes.

In  these muscle transplantation procedures, the muscle has to be reconnected to a blood supply (revascularized). This is done by connecting the vessels of the muscle  to new vessels in the face. This is where the concept of microvascular surgery comes in. With the development of the microscope, micro instruments, and particularly micro sutures, it became possible to consistently connect (anastamose) vessels of 1 mm in diameter.

The era of muscle transplantation for facial paralysis started because of the need to find new techniques and the introduction of the concepts and principles of microvascular surgery. This treatment has attracted a wide variety of patients with various forms of facial paralysis and has allowed for these techniques to be adjusted to their individual needs.

The program at Sickkids continues under the direction of Dr. Greg Borschel and Dr. Ronald Zuker. There are regular facial paralysis clinics where both surgeons evaluate the children and discuss their needs together and  formulate a surgical plan. The program is unique in its concept and in- depth focus.  Clinical research allows for ongoing adjustment in the interest of improved patient care.