Kofi Boahene says he’s the kind of guy who smiles a lot. Now he’s doing so even more—as are his patients.
Boahene, a professor in the Department of Otolaryngology–Head and Neck Surgery, and colleagues improved an existing operation to restore a more natural-looking, even smile to patients paralyzed on one side of the face following a stroke, brain surgery or other conditions. Normally, surgeons transfer a piece of muscle tissue from the thigh to the paralyzed side of the face, to help pull up the mouth to form a smile. But a smirk is the best this approach achieves, where just the corner of the mouth turns up, Boahene says: “A really nice smile where the lips open up, the corners move, you see teeth and a sparkle in the person’s eye ... that’s not what we were achieving,” mainly because they were replacing just one of many muscles involved in animating the face.
The goal of the revised procedure, called a multivector gracilis muscle flap, is to try to replace as many muscles as possible to recreate normalcy. First, Boahene and colleagues study a patient’s face, noting the angle of the smile on the nonparalyzed side, including how many teeth show when smiling. Then, during the four- to six-hour procedure, they take a small piece of muscle from a patient’s inner thigh, tease it apart into two to three smaller strips, and place it in two to three directions at the corner of the mouth or the upper lip to the cheek and eyelid. Then, they connect it to arteries, veins and rerouted nerves, and adjust the muscle tension to make the person’s new smile symmetrical. They hide the incisions in the hairline or the crease next to the ear. A description of the operation was published recently in the journal JAMA Facial Plastic Surgery.
Most patients stay in the hospital for three days following surgery while doctors make sure the blood vessels are working well. About two to six months after surgery, patients notice a twitch in the transplanted muscles—a sign the nerves are working. Next, patients learn physical therapy exercises to practice their new smiles while looking in a mirror.
“Over the next year, the brain starts rewiring this new muscle to try to make it part of the face, so you see the movement continue to get more sophisticated,” Boahene says. “Some people tell me, ‘I’ve been paralyzed all my life, and I was told there’s nothing that can be done.’ That’s not correct. I’ve seen patients paralyzed from one year to 50 years. Some people are actually born without the right muscles so they’ve never known how to smile. They are still candidates.”
More than 50 patients have undergone the procedure at Johns Hopkins, says Boahene, and their renewed smiles are so contagious that one can’t help but smile back: “Never let anyone tell you there’s nothing that can be done, because in almost every situation there’s an improvement we can achieve.”