Rebecca Grasso had simply woken up from surgical procedure when she first met Nate Jowett. His introduction was a shock; Grasso didn’t acknowledge him from her authentic group of docs tasked with shrinking an enormous tumor compressing her brainstem.

When he talked about nerve restore as his specialty, Grasso may sense one thing incorrect. One look within the mirror revealed the left facet of her face wasn’t shifting.

“I’m somebody who had the nickname ‘Smiley’ my entire life,” stated Grasso, a 30-year-old bodily therapist from Albany, New York. “To not acknowledge that smile — not to mention that individual staring again at me — was horrifying.”

Her facial paralysis couldn’t have come at a worse time. Grasso had deliberate to marry her fiancé, Matthew St. Pierre, in a matter of months and had already endured blow-after-blow to her once-perfect well being. The tumor in her head manifested from a uncommon hereditary situation referred to as neurofibromatosis kind 2, or NF-2, which had robbed her of her listening to simply two years prior.

However Jowett, a head and neck surgeon, wasn’t able to let the situation take away her facial features. There was nonetheless a chance to avoid wasting Grasso’s smile via a surgical approach generally known as a nerve switch, however time was of the essence.

A uncommon illness that begins deep within the cranium

The indicators and signs of NF-2 fluctuate from person-to-person, in accordance with the Nationwide Institutes of Well being. In Grasso’s case, she didn’t expertise signs till highschool. What started with problem listening to her academics cascaded into an incapability to listen to her tv on its loudest quantity. Then, throughout her sophomore 12 months of faculty in 2019, she observed a mysterious ringing in her ears.

“I’d continuously ask my classmates, ‘Did you hear that?’” Grasso defined. “After they had no concept what I used to be speaking about, I knew I wanted an MRI.”

Grasso’s exams revealed noncancerous tumors — generally known as schwannomas — on a number of nerves in her head. Two of the tumors had grown on nerves important for listening to and stability. By the point she completed faculty and graduate college, Grasso had misplaced practically all her listening to, and the tumors had begun compressing either side of the brainstem. To halt the expansion of her tumors and qualify for an auditory brainstem implant, she enrolled in a scientific drug trial at Massachusetts Basic Hospital. She would additionally endure a collection of operations to shrink, or debulk, each tumors.

Grasso first underwent surgical procedure nearer to house in New York to debulk the tumor on the precise facet of her brainstem. The tumor on the left facet, nevertheless, continued to develop at a fast tempo, additional compressing the brainstem and threatening her life. Debulking the second tumor would threat collateral harm to surrounding nerves, and the facial nerve specifically.

Given the huge dimension of Grasso’s tumor, the chances have been stacked in opposition to her by the point she arrived at Harvard-affiliated Mass Basic for her second surgical procedure. Whereas the process efficiently shrank her tumor and relieved her brainstem compression, she awoke to facial palsy.

Rewiring a smile

In some situations, facial nerves can spontaneously get better from damage. In the course of the second surgical procedure, surgeons preserved Grasso’s facial nerve, hoping the nerve would get better over the subsequent a number of months. Jowett monitored Grasso’s progress and ready to schedule a microsurgical nerve switch if her face remained paralyzed.

Nerve transfers re-route nerve fibers from a much less vital nerve to a extra necessary goal, with the aim of restoring necessary sensations or actions. In line with Jowett, an assistant professor of otolaryngology at Harvard Medical Faculty, nerve transfers needs to be carried out inside 12 to 18 months after the onset of facial paralysis for optimum outcomes.

“Time is muscle,” Jowett stated. “The efficacy of nerve switch procedures to revive necessary actions, resembling smiling and blinking, decreases with longer durations of paralysis as muscle tissue develop into much less receptive to neurotization.”

Eight months after her facial palsy began, Grasso confirmed no signal of bettering perform on the left facet of her face. So, in an preliminary process, Jowett labored with fellow Mass Eye and Ear surgeon Tessa Hadlock to re-route fibers from a nerve department controlling jaw motion to the department controlling Grasso’s smile. A number of months later, when Grasso had not recovered ample perform within the the rest of the left facet of her face, Jowett and Hadlock ready for a second nerve switch.

On the top of the COVID-19 pandemic, Grasso awoke at 2 a.m. for a four-hour drive to Boston from upstate New York. This time, her surgeons opted for a unique kind of nerve switch that re-routed nerve fibers chargeable for controlling Grasso’s tongue. The process —  a hypoglossal nerve switch — got here with its justifiable share of dangers; re-routing too many nerve fibers may end in a paralyzed tongue, whereas re-routing too few fibers would end in procedural failure.

To reduce the danger of problems, Jowett utilized a novel surgical strategy he and his group had employed on a number of prior circumstances. The strategy modified a traditional hypoglossal nerve switch by re-routing extra nerve fibers chargeable for controlling small muscle tissue in her neck. Connecting these extra fibers to the facial nerve would, in idea, cut back the proportion of hypoglossal nerve fibers required to revive symmetrical muscle tone in Grasso’s paralyzed face.

Solely time would inform if it could work for Grasso.

The return of “smiley”

Quite a bit has modified since Grasso’s final operation. Grasso and her fiancé purchased their first house collectively and celebrated their wedding ceremony on a rescheduled date. Becoming a member of the couple for the large day was a well-known sight: The earliest indicators of “Smiley” slowly — however certainly — returning.

“I’m constructing again my smile utilizing the nerves I take advantage of to chunk and flick my tongue,” stated Grasso. “It took weeks to see outcomes, however, since my second surgical procedure, I’ve seen my face return somewhat extra every day.”

In line with Jowett, it may possibly take as much as two years for a affected person to see the complete results of nerve switch procedures. To Grasso’s shock, the surgical procedures had improved her smile inside just a few months and her facial tone inside a 12 months. After a number of appointments with Facial Nerve Middle bodily therapist Mara Robinson to optimize her surgical consequence, Grasso was able to schedule her wedding ceremony for June 2021 — effectively forward of her restoration schedule. Whereas her NF-2 nonetheless leaves open the opportunity of her tumors returning, Grasso rests assured realizing she has a group of world-class facial perform consultants taking care of her.

You don’t need simply anyone working in your face,” Grasso stated. “You need the most effective of the most effective. Mass Eye and Ear actually is on the cutting-edge of those nerve procedures, which made seeing Dr. Jowett such a straightforward option to make.”