Interviewer: Facial paralysis can happen to a person for a variety of reasons, from nerve damage to disease, as well as conditions like Bell's palsy. While there are many treatments available to give back a person's ability to move their face or treat acute facial droop, for patients with long-standing paralysis or incomplete muscle recovery, surgery may be the best option to reanimate their face. It's called free functional muscle transfer, or FFMT for short.
And to help us better understand the procedure, and how it can help someone get back their smile, we're joined by Dr. Robert Teixeira. He is an Assistant Professor of Surgery within the Division of Plastic and Reconstructive Surgery at University of Utah Health. Dr. Teixeira, let's start with the basics.
What is Free Functional Muscle Transfer (FFMT)?
Dr. Teixeira: So free functional muscle transfer is really like a transplant of your own muscle to somewhere else. We're specifically talking about doing this for facial reanimation. So it's taking a muscle from somewhere else in your body, and transplanting it to your face, to re-hook up the blood vessels, to re-hook up nerves, and to anchor that muscle such that it'll provide a new function like smiling.
Interviewer: If we're doing a transplant . . . I've had Bell's palsy. We've had pieces before talking about some of the other ways that we can treat, say, nerves to fix facial droop, etc. But why would FFMT be a good option for certain types of patients?
When is Free Functional Muscle Transfer (FFMT) a Viable Option?
Dr. Teixeira: Generally, they're the patients who have some sort of facial paralysis that doesn't get any better after a year or more, and they have a bad chance of recovery. We talk about Bell's palsy, how most people start to get better within a few weeks, and if not, then it could be a few months. But if they still don't get better after that year mark, that's when we can start looking at doing a free functional muscle transfer.
Interviewer: So when you say longstanding symptoms or facial paralysis, are we talking three, four months, like someone with Bell's palsy? Is that when they should start looking at something like a muscle transfer surgery? Or is it longer? How long should they be experiencing paralysis before this is an option?
Dr. Teixeira: Generally, most patients experience at least a year, if not more, of paralysis prior to undergoing free functional muscle transfer. The reason why we do it that way is to make sure that they don't recover from their facial palsy. It's a big surgery to undergo, so you want to make sure that they're not going to get better on their own before doing something so drastic, if that makes any sense.
Interviewer: Understood. Yeah, it sounds pretty . . . I mean, as a layperson, it's sounding pretty intense. I mean, you're harvesting a muscle from somewhere else and putting it on my face.
It can be really impactful to lose movement in your face. What are some of the symptoms, outcomes, or struggles that people with facial paralysis deal with on a daily basis that might lead them to consider an operation like this?
Dr. Teixeira: The most common part of the face that we reanimate with the muscle that we use with free functional muscle transfer is for smile. So we smile and we have all these dynamic movements of our mouth, and it's so important in communication. When patients lose that ability, it can definitely have devastating consequences, even from a psychological aspect.
So this is where doing this surgery can improve that smile, it can improve quality of life, it can actually help improve oral competence, so that means not drooling, and also help improve some aspect of speech too.
Understanding the Free Functional Muscle Transfer (FFMT) Procedure
Interviewer: Wow. So you basically are taking a muscle or two in the face that controls the smile and replacing it with a new muscle. Are you swapping them? How is that going on? What's going on there?
Dr. Teixeira: So what happens is when you get facial palsy, longstanding, the muscles in the face don't fire anymore. And so they actually shrivel down a little. And when that happens, you lose that volume of that face.
So when we do the surgery to transplant the muscle, we actually just kind of put it right on top of it, and we attach the muscle to an area nearby your cheek, and then attach it to the area nearby your mouth to help provide that dynamic smile.
Interviewer: Wow. That's impressive. And so you're bringing along what? Nerves and blood flow? Is there any difference in, say, the transplanted muscle and the muscle that they had before?
Transplanting the Muscle
Dr. Teixeira: Generally, the muscle that we transplant is much bigger than the muscle they had before. And so we do a lot of things before we transfer it. One thing that we like to do is try to decrease the volume of the muscle and the weight of the muscle.
The muscle that we generally take is called the gracilis muscle. It's on the inside of your thigh. It's a redundant muscle in terms of your thigh functioning. And because it's from your thigh, it's much larger than anything in your face, so we really try to shave it down.
With regards to what we bring with it, in order to do a successful free functional muscle transfer, we need to reconnect one artery, we need to reconnect one vein at least, and we need to reconnect the nerve to help power that muscle and eventually power that function down the road.
Interviewer: Okay. So going back a little bit, you just said that it's a redundant muscle. I don't know, I just assumed that all my muscles... I needed them all. If you're harvesting a muscle from, say, my thigh, are there any complications or loss of function in my leg?
Dr. Teixeira: So the muscle that we take in the thigh is called the gracilis muscle. That muscle is definitely considered a redundant muscle. We use it in plastic surgery for free functional muscle transfer, facial reanimation, or even upper extremity reanimation. We also just use that muscle to help cover wounds elsewhere in the body. It's probably one of the most commonly harvested muscles for us.
People can have complications at that donor site such as bleeding, infections, and fluid collections, but overall complications like that are pretty low.
Interviewer: But after I heal, am I going to be walking funny, or is it that redundant?
Dr. Teixeira: You won't even notice.
Interviewer: Wow. Okay.
Dr. Teixeira: Unless you were maybe some sort of high-level Olympic athlete who did some sort of niche thing where you fired your gracilis, but the vast majority of people, myself included, no.
Potential Donor Muscles for Free Functional Muscle Transfer (FFMT)
Interviewer: So this thigh muscle, the gracilis, you say that you use it a lot, but are there other muscles that are taken for these types of procedures?
Dr. Teixeira: There are a couple of other muscles that can be used. Generally, the muscles that we choose need to be thin and small because we're replacing those types of small muscles in the face.
A couple of other options are the pectoralis minor, which is underneath your pec major in your chest, another small muscle. Another muscle people have talked about using is one of the feet muscles on the top of your foot called the extensor digitorum brevis. Both of these muscles, they're just not as good as the gracilis, but they are options in case someone didn't want their thigh operated on.
Free Functional Muscle Transfer (FFMT) Surgery Details
Interviewer: Say a patient has experienced facial paralysis for a long time. They've maybe tried some other options and it's not quite working for them. On the day of the procedure, what does that look like? Is this an outpatient procedure? Are they in there for 10 hours, 12 hours, overnight? What can they expect on the day of the surgery?
Dr. Teixeira: So this surgery is a longer procedure. It takes generally at least six hours, if not more. It is not an outpatient procedure. You'll need to be admitted to the ICU right afterward.
ICU is mostly just for monitoring the blood vessels and the reconstruction that we did. Because when we reconnect any sort of blood vessel in the body, there's a chance that those blood vessels can clot off. And the time that they would clot off would be normally within the first 48 hours.
So our protocol here is any sort of free functional muscle transfer, they go to the ICU for at least 48 hours post-op. Then after that, probably an extra two, or three days in the hospital, such that they'll be outside of the hospital by post-op Day 4 or 5 ready for a discharge.
Interviewer: Okay. And during that time period, you're doing the harvesting and the facial reanimation?
Dr. Teixeira: A lot of times we like to do this procedure as a two-team approach. So me and one of my partners will proceed with this. One of us will be harvesting the muscle, so that means finding the muscle on the thigh, the gracilis muscle is most commonly the taken one, finding that muscle, finding those blood vessels, finding the nerve to it, making sure that they're all clean and looking healthy.
At the same time, my other partner would be working in the face, more or less making a kind of a facelift incision, making a little pocket to put the muscle in, and finding the blood vessels for us to connect to, such that everything goes smoothly.
And then finally, finding a good nerve to power the muscle transplant down the road. There are a bunch of different options for that. One of the most commonly used ones is the masseter muscle, which is one of the muscles on the side of your jaw when you bite down.
Interviewer: Oh, okay. Six hours? Is that what you're saying? Give or take.
Dr. Teixeira: Six hours, eight hours. Yeah.
Recovery and Rehabilitation After Free Functional Muscle Transfer (FFMT)
Interviewer: In the hospital for a couple of days for observation, just making sure everything worked out. What happens recovery-wise? After they are discharged from the hospital, how long until they start to heal, until they can start to move their face again? Is there physical therapy? You just moved a muscle around. Can you just start smiling after you're out of the hospital, or does it take some time?
Dr. Teixeira: After this type of surgery . . . It's a big surgery, so there's going to be a lot of bruising, there's going to be a lot of swelling, and patients could be having some pain afterward. After a couple of weeks, generally, those things die down. And then there's a long waiting period for the nerves to reconnect.
So what happens is, because we reconnect the nerves, those nerves grow from their cut end from the face into the muscle. And that time period, it could be about six months before it starts firing, if not a little bit more. And then as it starts to fire, it'll eventually get stronger.
And depending on the nerve that we use to control that muscle, the therapy could differ. So after this type of surgery, therapy is absolutely necessary.
Long-Term Expectations and Outcomes
Interviewer: So we're talking six months, eight months. It takes quite a while for everything to start working again. And how about long-term? I mean, once they do start getting functioning, is this something that only lasts for a while, or is this the rest of your life?
Dr. Teixeira: Generally, I would say about the one to two-year mark, that's kind of when you know what your final result will be after the muscle transfer. The good part is that what you get then is what you get for life, anything crazy aside. By the two-year mark, that's what you get.
Insurance Options for Free Functional Muscle Transfer (FFMT)
Interviewer: Well, this sounds like a pretty serious procedure, and I think that on people's minds, it's not just the recovery or the results, but can they afford it? Is this type of procedure . . . considering you work with plastic surgeons and stuff, and we know that sometimes those aren't covered, is this covered by insurance?
Dr. Teixeira: Yes. This is a functional operation. This affects people's quality of life. This is something that should be, and is, covered by insurance. And if insurance carriers deny it, we would try to write letters of prior authorization to support the cause to undergo this type of surgery.
Interviewer: And so, as always, check, call your people, etc., but it's good to know that this is something that's typically covered.
Improving Quality of Life through Free Functional Muscle Transfer (FFMT)
So what can a patient expect for their outcomes? I think that that's always really important when we talk about a procedure, right? Are they going to smile the same as they did before? Can they expect an improvement in life? When you're talking to a patient, what are the typical outcomes that you can confidently have them expect?
Dr. Teixeira: Good long-term outcomes after this include improved symmetry with a smile. It's not going to be perfectly symmetric. But normally, patients come to us and they can't even raise that side of their face at all. They can't even raise that side of their mouth. And just by gaining at least three millimeters or more of motion at the corner of the mouth, that really improves that smile. A vast majority of patients can expect that.
A vast majority of patients also experience a much-improved quality of life after this type of surgery, such as improved facial symmetry, which helps with social interactions with other people and makes them feel more whole because they've regained that function that they lost.
Interviewer: That's got to mean so much to some patients. So it sounds like this is quite a procedure, but can have some really impactful outcomes for certain patients.
I want to ask if, say, a patient or a loved one is listening right now, and they're experiencing this facial paralysis, and it's been a while, but they might be concerned with the surgery and whether or not to go through with it, what is something with your experience that you could tell them or say to them to give them a peace of mind if this is an option worth looking into?
Dr. Teixeira: This is a safe operation, and it's effective in terms of improving that smile, that symmetry, and it's effective in terms of improving quality of life, helping out with social interactions, and helping out with mental health.
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