Options from Boston

In both Cleveland and Boston, they took many photos and video showing the same sequence of movements: relaxed, eyebrows up, close eyes lightly, close eyes tightly, small smile - lips closed, big smile, show your bottom teeth.  In Boston we started with these photos and video.  Next, we when into the doctor's office.  This is the first time I've ever been in a doctor's office that actually looked like an office.  It wasn't an exam room.  It was like on TV shows or movies when patients are in an actual office with book cases, a gorgeous view, couches, and beautiful wood desk.  The doctor had me sit across from her at her desk while her residents and PA sat on the window sill behind her.

The doctor after watching me talk for a few and do some movements, she explained how her office works.  She only sees new patients on Fridays.  The rest of the week she's in surgery.  She explained that she was going to speak off-the-cuff on her recommendations, but that in a week (May 10, 2013) she and her team will look again at all my photos and videos and come up with an official plan.  After the plan is finalized, they will send me a letter with options and recommendations.

While speaking off the cuff of what she'd propose to do, she said, due to the movement I do have available, she'd want to treat my face zonally.  She proceeded to give her recommendations from the top of my face, working her way down.

Forehead

Both in Cleveland and Boston they were not concerned about getting movement in my forehead; they were more focused on wrinkle control.  Cleveland said specifically they would not recommend a muscle transfer for my forehead, because the forehead surgery is notorious for being unsuccessful.  They also mentioned, that most people, when they look at your face, don't pay much attention to your forehead.  

Because my strong eyebrow has been in use for so long, it is actually a little lower than my weak eyebrow.  Also, I'm starting to get some aging wrinkles on the one working side, and not the other.  The doctor recommended Botox for my forehead.  By injecting Botox below my eyebrow on the good side, it would raise that eyebrow a little bit to make my eyebrows line up better.  Then by injecting Botox into two places in my forehead it would reduce the movement of my forehead enough to discourage those wrinkles.  Below is an image of where they would do the Botox injections:

The idea around wrinkle control is that the more the wrinkles are uneven between the two sides of the face, the more people will notice there's something off about my face.  There are strategies to gain wrinkles on the weak side and reduce wrinkles on the strong side.  For my forehead the goal is to reduce the wrinkles on the strong side.

Eye

Previously when I was at Mayo in Rochester, 10 years ago or more, they said that they could insert a gold weight in my eyelid to help encourage more closure.  In Boston, they recommended putting in a platinum weight.  Platinum is heavier, so they need less material, so it is less noticeable.  The doctor was very specific to let me know that patients, like me, who have paralysis from birth usually end up hating this treatment.  While I don't have any dry spots on my eyeball and it's currently healthy, I have built up a callus from not being able to close it for 29 years.  While the doctor did advise it would be a good idea to do to protect my cornea a little more, she said that in people like me she often ends up taking the weight out because the patients don't adjust well.  She did say to take the weight out, it was only a 10 minute procedure in the office.    So something to think about.

Nose

For my nose, she would take muscle sheath from the outside of my leg, to create a tendon that would pull my  nose back into place.  The tendon would stretch from my nose to somewhere close to my ear.  It would not be attached to a muscle group like the Cleveland proposal.

Upper lip

There are three options for this zone.  The goal is to get a smile crease similar to what I have on the strong side.

Option 1:

Similar to Cleveland, she would take a sheath from the outside of my thigh to make a tendon.  She would then attach one end of the tendon to my upper lip and attach the other end of the tendon back by my ear somewhere.

Option 2:

This is a one-phase surgery with a 90-something percent success rate.  There are four muscle/nerve groups, on each side of your face, that help you chew.  She would divert one of those chewing muscles to the upper lip area to gain movement there.  In order to activate this smile, I would need to bite down first to activate the nerve/muscle group.  

I'm not sure I like this plan very much.  Yes, I'd be able to pose for pictures, but who laughs while clenching their teeth?  Doesn't seem very natural to me.

Option 3:

This is a two-phase surgery and has a 1 in 5 chance it won't work.  This is the option of using a nerve from the outside of my calf to graft from the good side over to the weak side, then in the second surgery attaching a muscle from my inner thigh to the nerve graft.  Essentially, when I activate the right side of my face, it would simultaneously activate the left side. 

They said this would be the best natural smile.  It offers the most symmetry.  It does have a higher failure rate.  I asked what failure meant, and was told I wouldn't be out anything.  They were very confident they would not damage any of the movement I already have.  So if this surgery wouldn't work we just move to a plan B.

Lower Lip

The issue with my lower lip is that the strong side is too strong.  When I smile and talk, the strong side pulls the weak side over more than necessary.  The recommendation here is to use a Botox injection to weaken the good side of my lower lip to reduce some of the pulling.  Below is a picture of where they will put the Botox:

I did actually go ahead and get the lower lip Botox while we were there.  It only lasts for 3-4 months.  Watch for my next post.  It will be all about my first Botox experience.