By ROBIN GAITENS
UNC Health Care

CHAPEL HILL -- Thanks to a plastic surgeon at the University of North Carolina at Chapel Hill, 8-year-old Julian Lopez has a reason to smile.

He underwent nerve transfer surgery to correct facial nerve paralysis and restore movement in his face.

Lopez was diagnosed with congenital facial paralysis shortly after his birth. His mother, Deborah Losoya, said doctors first noticed the problem in the delivery room. "I noticed it, too. One side of his face didn’t move when he cried," said Losoya, of Fayetteville. The doctors ordered a MRI, which showed that Lopez’s right-side facial nerve had not developed.

Lopez’s appearance looked similar to that of a stroke patient and he experienced many of the same challenges -- problems chewing and drinking, the inability to fully close his eye and difficulty with speech articulation. Though he received speech and occupational therapy and participated in sports and other activities, he could not avoid the ridicule he received from kids and adults.

"Julian started to withdraw. He would bow his head to hide his face," said Losoya. "More than anything, he just wanted to be able to smile."

Such sensitivity is common, said Kim Uhrich, clinical social worker at the UNC Craniofacial Center.

"Children recognize the difference between pretty and unattractive around age 4. By age 8, it reaches its pinnacle," Uhrich said. "I tell parents if they start to see changes in their child’s socialization or behavior that we need to pull out all the stops and see if there is anything that can be done."

In May 1997, Losoya and Lopez met with Dr. Gerald Sloan, medical director of the UNC Craniofacial Center and chief of the division of plastic surgery at the UNC-CH School of Medicine, to discuss options.

"What bothered Julian most was his smile," Sloan said. "Fortunately, he was not experiencing any other complications associated with not being able to close his eye, such as drying out or corneal damage, so we felt it was important to focus on restoring his smile."

Sloan recommended a nerve graft to correct the paralysis, but cautioned that the success rate was only 25 percent.

They were willing to take the chance.

In August, Sloan grafted a nerve from Lopez’s leg to his cheek. During the eight-hour surgery, Sloan removed the sensory nerve from the back of Lopez’s calf and, using a microscope to see the fine, nylon stitches smaller than a human hair, he attached the transferred nerve to the functioning nerve branches in Lopez’s left cheek.

Next, he channeled it across Lopez’s upper lip and chin to the right side of his face. The final step was to wait and hope the nerve would regenerate and restore feeling and movement to Lopez’s face.

"With older kids, we have to make sure that their expectations meet the reality," Ulrich said. "In Julian’s case, we were not sure what kind of return, if any, we were going to get, or how long we were going to have to wait."

Generally, nerve regeneration takes months, and Lopez was no exception. More than six months after the surgery, Losoya saw the first signs that it had been a success.

"I started noticing a slight motion when he smiled and his eye was closing better," she said. "But I did not want to get his hopes up until we were sure it had worked."

During one of the routine Tinel-sign tests, in which Losoya would tap Lopez’s face with her fingers to create a tingling sensation (not unlike a doctor tapping a patient’s knee to check reflexes), she got her confirmation.

Losoya explained: "Dr. Sloan said if Julian felt ‘pins and needles’ in his face, then that would indicate that the nerve was growing. One day during the test, Julian said he felt a little bit of ‘electricity’ in his cheek and a lot above his lip."

They called Uhrich with the good news.

A follow-up appointment with Sloan confirmed that Lopez’s surgery was indeed a success -- so much so that he would not need a second operation.

"Most patients also require a muscle transplant to restore the muscle tone in the cheek," said Sloan. "Julian, however, is able to achieve the same results simply by doing daily facial exercises."

Today, more than a year after his surgery, Lopez continues to improve. The surgery not only increased the movement in his face, but also boosted his self-esteem.

"He is much more outgoing and is so proud of the scar on his leg," his mother said. "By God’s grace, and Dr. Sloan, we got a lot more than we ever had hoped."

Congenital facial paralysis is fairly uncommon, affecting less than one in 10,000 people. Though Lopez was Sloan’s first patient in North Carolina to have surgery to correct this type of birth defect, the UNC Craniofacial Center team follows more than 850 patients with birth defects including craniosynotosis, cleft lip, cleft palate and absent ears. Sloan sees approximately 150 new patients from across the Southeast each year.

The UNC Craniofacial Center is affiliated with the schools of medicine and dentistry and UNC Hospitals in Chapel Hill.

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