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Microsurgical Facial Reanimation in Children Less Than Three Years Old: The Case for Early Intervention
George D. Xipoleas, M.D., Eric M. Jablonka, M.D., Elliott H. Rose, M.D., Jess Ting, M.D., Peter J. Taub, M.D., Linda M. Carroll, PhD, Jeffrey T. Laitman, PhD.
The Mount Sinai School of Medicine, New York, NY, USA.

Background:
Traditional teaching at most institutions dictates that facial reanimation procedures are initiated at the ages between four and a half and six years old when the vessel and nerve anatomy is of greater caliber for microanastomosis and the children are more cooperative. The disadvantage is that permanent compensatory speech patterns and altered facial expressions have developed by this age to accommodate the unilateral facial paralysis. With the goal of completing facial reanimation by the time of initial speech training, five cases were performed on children less than three years of age at our institution to determine the feasibility of early intervention in reanimation of the developmentally paralyzed face.
Methods:
The two stage procedure employed introduction of two cross facial nerve grafts and static fascia lata slings to achieve static symmetry at the first stage followed at six to eight months by distal neurorrhaphy to the orbital branch of the facial nerve and microsurgical transfer of a free gracilis muscle motored by the cross facial buccal branch. One child with CHARGE syndrome was excluded from the study because of anatomical abnormalities of the recipient vessels.
Evaluation of smile restoration in the four cases was monitored by clinical exam, photographic and video analyses, and digitized smile recognition software. Feedback was obtained from parents and speech pathologists regarding development of speech patterns and attainment of developmental milestones of physiological activities of daily living.
Results:
All four of the toddlers studied achieved full static symmetry in repose and seventy-five to one hundred percent of dynamic smile restoration (documented by independent evaluators). Development of physiological activities of daily living such as cup feeding, drinking through a straw, chewing, fluid retention has progressed normally without the need for retraining of aberrant compensatory facial mechanisms. Feedback from the speech therapists and parents has confirmed that speech patterns have developed at normal landmarks and have not required specialized retraining as is so a characteristic of children operated at older ages after poor speech patterns and altered facial expressions have developed.
Conclusion:
Restoration of facial nerve “specific” innervated motor mechanisms coincides temporally with “imprinting” patterns of speech development and anatomical descent of the larynx. Despite the greater challenge of more meticulous dissection and difficult microsurgical repair, restoration of smile and symmetrical facial expression can be achieved with intervention as early as eighteen months to facilitate normal patterns of speech and motor development of facial expression thereby precluding the need for later retraining of essential facial motor functions.


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