For the first time in her young life, an 11-year-old girl from Virginia is able to smile using the right side of her face.
Nicole Serna-Gonzalez was diagnosed at birth with unilateral facial paralysis, which prevented her from closing her right eye, smiling on the right side of her face, or using that side of her face to show emotion.
Doctors initially told her family that the condition might go away, and that it could've developed during childbirth if her face was pressing against something.
"In the beginning, we had hope that it would go away with time, though we didn't think much of it," said her mother, Carolina Gonzalez. "It didn't affect her in any way except that she couldn't smile. She could eat and her speech wasn't impaired by it. She could swallow."
Nicole's smile was different, her mother said, and she liked having a different smile. Still, some people made her feel uncomfortable in the way they asked about it.
Her family spent years trying therapy and searching for proper treatment, and after a few years of planning and interruptions from the pandemic, surgeon Dr. Patrick Byrne and a team of staffers performed Nicole's 10-hour facial reanimation operation, allowing her to slowly develop use of the right side of her face and smile.
The procedure, called a trivector gracilis free tissue transfer, is the first procedure to produce a contraction of the lower eyelid and around the eyes, creating a natural smile.
Nicole is the first to undergo the surgery.
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What is unilateral congenital facial paralysis?
Nicole's condition, unilateral congenital facial paralysis, is usually diagnosed at birth.
Sometimes the delivery team notices within the first few hours of birth that one side of the baby's face is immobile, Byrne said.
It can be caused by birth trauma, like when medical professionals use forceps during the delivery and mistakenly crush a facial nerve. Other times, it's deemed a birth defect.
"There are these subtle cases which only affect part of the facial nerve," Byrne said. "In those cases, it can sometimes be weeks or even months later that people notice."
He met Nicole around 2018 when he was at Johns Hopkins. Finding someone to treat the condition in children can be difficult, he said.
They planned to perform her operation in 2019 but the pandemic halted things, then Byrne moved to the Cleveland Clinic.
"They were a little lost for a while and ultimately tracked me down and showed up in Cleveland," he recalled. "We were able to proceed with treating her."
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Evolving treatment for children's facial paralysis
The operation Byrne performed, a tri-vector gracilis free tissue transfer, is the first of its kind; it evolved from a procedure created decades ago where surgeons implanted a leg muscle into the face.
The leg muscle pulled on the corner of the mouth, allowing patients to generate a smile. But the resulting smiles pulled the corner of the mouth up in an unnatural way, Byrne said.
He and other surgeons at Johns Hopkins spent years trying to perfect a different technique, the multivector gracilis muscle flap, where surgeons take a section of the gracilis muscle, located on the thigh, and separate it into two smaller strips. They then insert the muscle into the face at the corner of the mouth or upper lip to the cheek and eyelid.
"Still, it was noticeable that the patients who received this procedure had a problem with their face because the eye remained adynamic ... silent," he said.
Research has shown that when people smile intentionally, there is no movement around the eyes. When people smile naturally, their cheeks are lifted and there are crinkles around their eyes. These smiles, coined "Duchenne" smiles, are typically thought to be genuine, natural smiles.
The multi-vector procedure didn't address the area around the eyes, but Byrne's latest procedure on Nicole, the trivector gracilis free tissue transfer, does. During the procedure, Byrne's team added three slips of muscle versus two, including under and around the eyes for the first time.
A healing journey for Nicole
Nicole and her family trekked to Cleveland for her surgery in June 2021. She spent a few days in the hospital recovering before heading home. She returned a year later to check in.
Byrne said Nicole's smile "looks fully alive and dynamic." There's still some swelling but that's normal during the first few years after surgery.
Her mother said she's doing great.
"She sees the pictures now and she can tell a big difference," her mother said. "She likes her smile now. She liked it before too."
The 11-year-old has a big personality, her mother said. She loves playing basketball, taking care of animals, and art is her jam. She actually celebrated her birthday recently and got new art supplies.
Regarding her facial muscle, Byrne said it takes between four and 12 months for the muscle to wake up because the nerves have to grow and activate, and the healing process continues for several years.
It can be confusing on the body. The muscle once used to move legs is now being repurposed, he said. She should continue to see improvement for at least three years.
"She has a beautiful smile," he said. "There's really nothing, to me, more fascinating than this nuance of facial expression because it really is what makes us human in so many ways."
The family will meet with Byrne in the coming years to make sure everything's OK medically, said her father, Sergio Serna.
The process was hard for them all, including him and his wife as parents.
"We can rest knowing that we did everything that we could," he said. "She's happy. We're happy."
Her mother encourages people to teach their kids not to judge other people's bodies. Kids are curious and their intentions are not to be mean, but it happens, she said.
"It's a good lesson that I've learned as a mom," she said.
And about Nicole's big personality, it extends to others too, her mother said.
When she was leaving the hospital after surgery, she met a girl who was preparing for an operation of her own and gave her some encouragement.
"It's all worth it in the end," Nicole told her. Trust the process."
Saleen Martin is a reporter on USA TODAY's NOW team. She is from Norfolk, Virginia - the 757 - and loves all things horror, witches, Christmas, and food. Follow her on Twitter at @Saleen_Martin or email her at email@example.com.
This article originally appeared on USA TODAY: Patient with unilateral facial paralysis gets reanimation surgery