How to rebuild a smile: adults with facial paralysis undergo “smile surgery” at this Toronto hospital


We say so with a smile that it’s a universal form of communication that most of us take for granted.

But Luigi Quafisi lost the ability to smile because of a benign tumor called an acoustic neuroma located near his ear.

“Oh, he had a nice smile,” his 43-year-old wife Eva told CTV News. “He was always happy … and he smiled a lot before, yes. “

An acoustic neuroma is a slow growing tumor that grows on the main nerve leading from the inner ear to the brain. By swelling, it can cause hearing loss and disrupt facial function.

Quafisi was diagnosed at the age of 63. The tumor damaged the muscles and nerves in his face, making it hard for him to blink, eat and smile.

He couldn’t even smile for his six grandchildren, who often visited him.

Brain surgery removed the tumor in 2017, but it couldn’t repair the damage the tumor had already caused.

Quafisi told CTV News that the loss of movement in half of his face was difficult to manage.

“It bothers me a lot,” said Quafisi. “I can’t do what I did before. “

But a doctor from Toronto and a rare procedure offered him the chance to find his lost smile.

Only a few doctors in Canada offer what is called “facial re-innervation” to adults, and Dr. Heather Baltzer of the Toronto Western Hospital is one of them.

For her, a smile is more than just a smile.

“It changes the way you interact with your environment and it also changes the way people perceive and talk to you,” she told CTV News.

Baltzer, trained as a hand surgeon, started treating patients for facial re-innervation in 2016. Her first patient, a woman close to her age, Anastasia, had lost her smile due to a tumor like Quafisi.

It’s an emotional job for her. But when the hard work is done, she gets a one-time gain.

“When you see them smile for the first time, it’s the best feeling,” she said.

Facial paralysis can be caused by injuries, tumors or Bell’s palsy, and it takes a toll, often leading to depression and isolation.

Baltzer said that those who have lost the ability to smile feel the disconnection of being unable to present their emotions as they did before and like others expect them to do.

“It makes many patients very isolated and prevents them from wanting to interact outside the home,” she said.

She added that often they “tend not to see friends because they are worried about how they are going to be perceived.”

“So it’s probably a main thing [that] really impacts their quality of life. “

In 2018, Quafisi came for his first facial re-innervation surgery.

He has had a typical type of facial paralysis, said Baltzer, where there is sagging features on one side of a person’s face, and they are unable to close their eyes on the affected side.

“The inability to smile on this side of his face also has an impact on other functions like the ability to chew food and breathe through this side of the nose,” she said.

But although she had seen this paralysis several times before, one of the differences between Quafisi and some of her other patients was her age.

“Because Luigi is a little older than some other patients … which impacts [the] how nerves can regenerate and how long it takes nerves to regenerate, “said Baltzer.

The type of surgery that Baltzer specializes in for adults is most commonly performed in children.

Baltzer and his team had two main goals in approaching Quafisi’s facial surgery: to bring back his smile and restore the closure of the eyes.

In order to perform a cross nerve transplant, they first identified the nerves on the unaffected side that controlled the smile and the blinking.

Then they had to replace the damaged nerves on the paralyzed side of the face.

“We take the nerve from another part of the body,” said Baltzer, “and it acts as an extension from the normal side of the face to the affected side of the face. “

Baltzer took a nerve from Quafisi’s leg and carefully inserted it into his face, connecting it to the healthy nerves on the unaffected side.

This type of surgery does not instantly restore function to the damaged side, but new nerve fibers may begin to develop. This is an important first step so that other surgeries can build on this basic work.

The end goal is to regain that “spontaneous smile,” said Baltzer.

“So that when you laugh out loud, you smile on both sides of your face. “

Just over a year after Quafisi’s surgery, he shows a marked improvement. He can smile if he bites and concentrates.

Baltzer said work so far “makes him smile when he thinks about it.”

He needs more procedures to completely repair his sagging facial, but this is not possible at the moment COVID-19 has suspended his procedures.

For the moment, his smile must remain imperfect, but it is still a smile. When he turned 68 last April, he was able to celebrate by lifting the two corners of his mouth.

After so many difficulties, when his family smiles at him, he can return the gesture.

“I like it when he smiles,” said his wife.

Other patients with facial paralysis at the Baltzer Clinic in Toronto Western also find their smile.

“It’s the most exciting thing when they come back to [the] “Their nerve transfers usually start around three months old, and they are able to smile with … that side of their face, and every time I get goosebumps,” said Baltzer.


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