11-year-old girl undergoes first-of-its-kind surgery so she can flash her 'beautiful smile'

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For the first time in her young life, an 11-year-old Virginia girl can smile with 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 could have possibly gone away and developed during childbirth if her face had been pressed against something.
"In the beginning we had hope that it would go away over time, although we didn't think about it much," 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 was not affected. She could swallow."
Nicole's smile was different, her mother said, and she liked having a different smile. Still, some people felt uncomfortable asking about it.
Her family spent years trying therapy and searching for an appropriate treatment, and after several years of planning and disruptions caused by the pandemic, surgeon Dr. Patrick Byrne and a team of collaborators performed Nicole's 10-hour facial resuscitation surgery, which allowed her to slowly develop the right side of her face and smile.
The procedure, called trivector gracilis-free tissue transfer, is the first procedure that creates contraction of the lower eyelid and around the eyes, creating a natural smile.
Nicole is the first to undergo the surgery.
Nicole Serna-Gonzalez, an 11-year-old who was diagnosed at birth with unilateral congenital facial paralysis that left her unable to smile with the right side of her face. In June 2021, Nicole underwent 10-hour facial resuscitation surgery and has shown improvements.
Nicole Serna Gonzalez with Dr. Patrick Byrne of the Cleveland Clinic.
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What is Unilateral Congenital Facial Paralysis?
Nicole's condition, a unilateral congenital facial paralysis, is usually diagnosed at birth.
Sometimes, within the first few hours after birth, the delivery team will notice that one side of the baby's face is immobile, Byrne said.
It can be caused by birth trauma, e.g. when medical professionals use forceps during labor and accidentally pinch a facial nerve. In other cases, it is considered a birth defect.
"There are these subtle cases that only affect part of the facial nerve," Byrne said. "In these cases, it can sometimes take weeks or even months later for people to notice."
He met Nicole around 2018 while he was at Johns Hopkins. Finding someone to treat the condition in children can be difficult, he said.
They planned to have her surgery in 2019, but the pandemic halted things, then Byrne moved to the Cleveland Clinic.
"They were a little lost for a while and eventually tracked me down and showed up in Cleveland," he recalled. "We were able to continue with the treatment."
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Nicole Serna Gonzalez with Dr. Patrick Byrne of the Cleveland Clinic.
Nicole Serna Gonzalez.
Development of treatment for facial paralysis in children
Byrne's surgery, a tri-vector gracilis-free tissue transfer, is the first of its kind; It evolved from a procedure developed decades ago in which surgeons implanted a leg muscle in the face.
The leg muscle pulled at the corner of the mouth, allowing patients to produce a smile. But the resulting smile pulled up the corners of her mouth in an unnatural way, Byrne said.
He and other surgeons at Johns Hopkins spent years perfecting another technique, the multivector gracilis muscle flap, in which surgeons take a section of the gracilis muscle located on the thigh and separate it into two smaller strips. Then they insert the muscle into the face at the corner of the mouth or upper lip up to the cheek and eyelid.
"Nevertheless, what was striking was that the patients who received this procedure had a problem with their face because the eye remained adynamic...still," 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 wrinkles around their eyes. This smile, coined "Duchenne" smile, is typically considered a true, natural smile.
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 muscle twitches versus two, including under and around the eyes for the first time.
Nicole Serna-Gonzalez hugs Dr. Patrick Byrne of the Cleveland Clinic.
A healing journey for Nicole
Nicole and her family relocated to Cleveland for her surgery in June 2021. She spent a few days in the hospital recovering before going home. She returned a year later to check in.
Byrne said Nicole's smile "looks completely alive and dynamic." Swelling is still present, but this is normal for the first few years after surgery.
Her mother said she was fine.
"She sees the pictures now and can tell a big difference," her mother said. "She likes her smile now. She used to like it too.”
The 11-year-old has a big personality, her mother said. She loves playing basketball, caring for animals and art is her thing. She actually recently celebrated her birthday 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 are growing and need to be activated, and the healing process takes several years.
It can be confusing for the body. The muscle once used to move the legs is now being repurposed, he said. She should see improvement for at least three years.
"She has a beautiful smile," he said. "To me, there's really nothing more fascinating than that nuance in facial expression, because that's really what makes us human in so many ways."
The family will be meeting with Byrne in the years to come to make sure everything is medically okay, her father Sergio Serna said.
The process was tough for all of them, including him and his wife as parents.
"We can rest assured that we did everything we could," he said. "She's happy. We're happy."
Her mother encourages people to teach their children not to judge other people's bodies. Kids are curious and don't want to be mean, but it happens, she said.
"That's a good lesson I learned as a mom," she said.
And as far as Nicole's big personality goes, that extends to others, too, her mother said.
Leaving the hospital after the operation, she met a girl who was preparing for an operation of her own and encouraged her.
"It's all worth it in the end," Nicole told her. Trust the process."
Nicole Serna-Gonzalez with her mother, Carolina Gonzalez.
Nicole Serna-Gonzalez (left) with her mother, father and brother.
Saleen Martin is a reporter for USA TODAY's NOW team. She's from Norfolk, Virginia - the 757 - and loves horror, witches, Christmas and food. Follow her on Twitter at @Saleen_Martin or email her at sdmartin@usatoday.com.
This article originally appeared on USA TODAY: A patient with unilateral facial paralysis undergoes resuscitation surgery

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