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 staff of medical doctors tasked with shrinking an enormous tumor compressing her brainstem.
When he talked about nerve restore as his specialty, Grasso might sense one thing incorrect. One look within the mirror revealed the left aspect of her face wasn’t transferring.
“I’m somebody who had the nickname ‘Smiley’ my entire life,” mentioned 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 known as neurofibromatosis sort 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 save lots of Grasso’s smile by means of a surgical approach often called 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 individual to individual, 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 lecturers cascaded into an incapacity to listen to her tv at its loudest quantity. Then, throughout her sophomore yr of faculty in 2019, she seen a mysterious ringing in her ears.
“I might continually ask my classmates, ‘Did you hear that?’” Grasso defined. “Once they had no concept what I used to be speaking about, I knew I wanted an MRI.”
Grasso’s assessments revealed noncancerous tumors — often called 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 school and graduate college, Grasso had misplaced almost all her listening to, and the tumors had begun compressing each side of the brainstem. To halt the expansion of her tumors and qualify for an auditory brainstem implant, she enrolled in a medical drug trial at Massachusetts Common 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 appropriate aspect of her brainstem. The tumor on the left aspect, nevertheless, continued to develop at a speedy tempo, additional compressing the brainstem and threatening her life. Debulking the second tumor would danger collateral harm to surrounding nerves, and the facial nerve particularly.
Given the huge measurement of Grasso’s tumor, the percentages had been stacked in opposition to her by the point she arrived at Harvard-affiliated Mass Common 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 cases, facial nerves can spontaneously get well from harm. Throughout the second surgical procedure, surgeons preserved Grasso’s facial nerve, hoping the nerve would get well 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 reroute nerve fibers from a much less essential nerve to a extra essential goal, with the objective of restoring essential sensations or actions. Based on Jowett, an assistant professor of otolaryngology at Harvard Medical College, nerve transfers ought to be carried out inside 12 to 18 months after the onset of facial paralysis for optimum outcomes.
“Time is muscle,” Jowett mentioned. “The efficacy of nerve switch procedures to revive essential actions, akin to smiling and blinking, decreases with longer durations of paralysis as muscle mass turn into much less receptive to neurotization.”
Eight months after her facial palsy began, Grasso confirmed no signal of enhancing perform on the left aspect of her face. So, in an preliminary process, Jowett labored with fellow Mass Eye and Ear surgeon Tessa Hadlock to reroute 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 satisfactory perform within the the rest of the left aspect of her face, Jowett and Hadlock ready for a second nerve switch.
On the peak of the COVID-19 pandemic, Grasso wakened at 2 a.m. for a four-hour drive to Boston from upstate New York. This time, her surgeons opted for a special sort of nerve switch that rerouted nerve fibers accountable for controlling Grasso’s tongue. The process — a hypoglossal nerve switch — got here with its justifiable share of dangers; rerouting too many nerve fibers might end in a paralyzed tongue, whereas rerouting too few fibers would end in procedural failure.
To reduce the danger of issues, Jowett utilized a novel surgical strategy he and his staff had employed on a number of prior instances. The strategy modified a standard hypoglossal nerve switch by rerouting further nerve fibers accountable for controlling small muscle mass in her neck. Connecting these further 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”
Rather a lot has modified since Grasso’s final operation. Grasso and her fiancé purchased their first house collectively and celebrated their marriage ceremony on a rescheduled date. Becoming a member of the couple for the massive day was a well-recognized sight: The earliest indicators of “Smiley” slowly — however certainly — returning.
“I’m constructing again my smile utilizing the nerves I exploit to chunk and flick my tongue,” mentioned Grasso. “It took weeks to see outcomes, however, since my second surgical procedure, I’ve seen my face return a little bit extra every day.”
Based on 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 a number of months and her facial tone inside a yr. After a number of appointments with Facial Nerve Heart bodily therapist Mara Robinson to optimize her surgical final result, Grasso was able to schedule her marriage 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 understanding she has a staff of world-class facial perform specialists taking care of her.
“You don’t need simply anyone working in your face,” Grasso mentioned. “You need the most effective of the most effective. Mass Eye and Ear actually is on the innovative of those nerve procedures, which made seeing Dr. Jowett such a simple option to make.”
This story first appeared on the Mass Eye and Ear Focus web site.
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