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Helping Hannah Smile: The Mechanics Of Reanimation

Hanna Lockwood 2COARSEGOLD — The big day is finally around the corner.

Hannah Lockwood is having her smile surgery on Monday, July 25, as Dr. Andre Panossian deftly performs a procedure he’s been perfecting for ten years, known as the temporalis myoplasty.

Hannah, 6, has Moebius Syndrome. She was born without the seventh facial nerve — the one on either side of the head that enables movement of the face, including the ability to close the eyes, eat, suck, blow, and smile.

We first learned about Hannah back in May, when the community rallied around the Lockwood family to help raise funds for this life-changing surgery. In a stunning show of support, community, friends and family of the Lockwoods raised $46,250.

“It is amazing,” says Hannah’s mom Sarah Lockwood, filled with gratitude for the outpouring. As the Lockwoods prepared to leave Coarsegold for the trip to southern California where the surgery will be performed, a little bug showed up in the otherwise robust family. Some of the kids came down with a cough and one had a fever, potentially challenging Hannah’s surgery date should she become ill as well.

Hannah Sarah and Kevin Lockwood“We are excited but a bit nervous about surgery because of this bug that is going around the kids. It is exciting, though, to finally be at the point of seeing it happen after so many months of fundraising and planning.”

The Lockwoods received donations enough to pay for the surgery, as well as the complicated travel and housing arrangements needed when two parents and five kids go out of town for a week.

Dr. Panossian’s practice is in Beverly Hills, and the family in its entirety is attending a weekend conference on facial reanimation in southern California that began on Friday.

Dr. Panossian specializes in reconstructive surgery, including smile reanimation for people of all ages, and is recognized as an expert in the treatment of facial paralysis. Now, in a delicate eight-hour surgery, Dr. Panossian will give young and effervescent Hannah something she’s longed for, that most of us take for granted: the slight upturn of the mouth known as a grin.

The procedure is designed especially for patients with permanent facial paralysis, explains Dr. Panossian.

Dr. Panossian and Hannah Lockwood May 13 2016 photo by Sarah Lockwood“As far as Hannah is concerned, both of her facial nerves are missing,” says the plastic surgeon. “With Moebius Syndrome we are limited in the nerves we can use to reanimate the face, so we go down the list to see what other nerves are available in the face.”

In facial reanimation of this kind, Dr. Panossian engages the fifth cranial nerve, responsible for chewing and biting.

“It’s not a perfect match but it works. What we do is reanimate that upward pulling of the smile, that elevation of the mouth. It doesn’t change the movement of the face beyond that, such as puckering, for instance. ”

The nerves get smaller as they branch down into the face, says Dr. Panossian, and different nerves have different qualities based on how many nerve fibers they contain.

“A biting nerve is small but powerful, and the power-to-size ratio is really high. It contracts the muscle down tightly. We are not using the nerve itself but the temporalis muscle which sits on the side of the head and tightens when you clench your jaw. ”

Dr. Panossian takes advantage of the power in that biting muscle to reanimate the smile, and both sides are done on the same day.

“We detach it on one end, and rotate it and are able to extend that tendon all the way down and tunnel it underneath the skin and towards the corners of the lip. This ends up producing tension in the lower lip and corners of the mouth, and that’s what is absent now.”

The surgery will also improve other aspects of life and function for Hannah. She will have improved ability to coordinate the movement of food, improved lip closure and greater speech articulation. Hannah will clench her teeth in a bite to trigger the smile.

And there’s the crux of the matter, says Dr. Panossian — the smile.

Hannah Lockwood from Facebook 2016 photo by Sarah Lockwood“Why do we even bother with an eight-hour surgery, and what’s the big deal with a smile? Set aside the functional improvement and these are the reasons: it can impact the quality of life. The smile is a means of communication, it lets others know you acknowledge what they are saying. It’s important for first impressions, and social interaction. A smile is a big important part of human existence.”

When the smile is lost, or never present as in the case of people with Moebius Syndrome like Hannah, it is immediately noticeable, say the doctor.

“It instinctively puts an impression that something is wrong, or it can be perceived that the person is not intelligent, for example, and that’s the way they get treated. The other social implication is that someone is not happy or is being smug or, if they are not smiling at all, seems to be perceived almost as rude. They are masked by facial paralysis. The big deal is the whole social aspect of the smile.”

Hannah is at the ideal age to have this kind of procedure, according to the experts.

Hanna Lockwood 5“There are several ways to assess when a child is ready and who is a candidate,” Dr. Panossian continues.

“If it’s someone with permanent facial paralysis with zero chance to recover, then they are a candidate for the muscle transfer. Timing is important, you do it around five years of age when the parts are a little bigger to work with. The nerves are more robust and the child can better tolerate surgery.”

In addition to the physical aspects that make kids Hannah’s age good candidates for surgery, there are the reasons Hannah first expressed when her parents began to explore the idea of surgery.

“Children socialize more at that age as they enter kindergarten, and they have more interaction with peers. Any defect or deficiency is picked up in such a way that the child becomes socially aware of their own limitations. This kind of surgery can minimize that impact. Is she going to smile like everyone else? No, but the smallest amount of smile has an impact.”

Hanna LockwoodDr. Panossian agrees with the consensus that the Lockwoods are an amazing family. All that’s needed now, for the surgery to take place on Monday, is for Hannah to maintain optimum health this weekend. The Lockwoods are working on that.

“Eli seems to be the only one with a fever right now but three of them, including Hannah, have coughs,” says mom Sarah Lockwood. “So far it doesn’t look like it will affect the surgery but we will see if anything changes over the weekend.”

Following this weekend’s Moebius syndrome conference, Sarah’s mom will fly down to watch the other four kids while Hannah is in surgery.

“Yesterday I was running around like a chicken with my head cut off trying to pack for a week for seven people and four places to stay, plus surgery, recovery, other kids not having surgery, and fit it all in our Sienna,” says Sarah.

Hannah first met with Dr. Panossian back on May 13, and that’s when the family knew they would be moving forward with the surgery.

“Dr. Panossian spent an hour with us talking about every aspect of the procedure, recovery times, what to expect after the surgery. He talked with us and he talked with Hannah equally. He even joked about how she loves chewing gum and likes it as much as his five-year-old daughter. He also talked a lot about the reasons he does the surgery in the private surgical center next door to his office, instead of a big hospital. He made us feel so very comfortable.”

Lockwoods in the car by Sarah Lockwood July 15 2016The Lockwoods made it to southern California today without complication, and if all goes as planned, Hannah will be smiling soon.

“Everyone is super excited now. In the first days after the appointment, Hannah was much more nervous and expressed fear over the surgery. She has had lots of surgeries but this the first one that she has had any say in — the rest were when she was little and were medically necessary when they happened. Since the major fundraising started at her school, the excitement has built in her and she is feeling a bit like a super star. It has been incredible to watch people go above and beyond to love and support her.”

(Editor’s note: Hannah’s surgery had been scheduled for Monday, July 18, but has been postponed until July 25.)

Read the original story about Hannah on SNO.

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