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Health Matters: Providence Saint John's Health Center | 11 A Smile Returns Dr. Amit Kochhar performs an advanced type of facial nerve surgery that restores movement and function in patients with facial paralysis. I magine a world without the ability to smile, where every expression of joy, happiness and connection is constrained. This is the reality for those with facial paralysis, a condition that strips away not only their ability to communicate, but diminishes their emotional experiences. However, there is hope on the horizon in the form of dynamic facial reanimation surgery, a groundbreaking procedure performed by Amit Kochhar, MD, at Providence Saint John's Health Center. Dr. Kochhar, director of the Facial Nerve Disorders Program at Providence Saint John's Health Center's Pacific Neuroscience Institute (PNI), is one of a small number of surgeons who perform dynamic facial reanimation, a surgery that may involve rerouting nerves and muscles of the head and neck. Facial paralysis, caused by various factors such as Bell's palsy, Ramsay Hunt syndrome or a head or neck tumor, typically affects only one side of the face. In the most severe cases, Dr. Kochhar performs a gracilis free tissue transfer, an intricate procedure involving the transplantation of a muscle from the leg to restore facial movement. "It's a procedure so rare that about 10 doctors in the state of California are skilled enough to undertake it," says Dr. Kochhar, who is double board-certified in otolaryngology and head and neck surgery, as well as facial plastic and reconstructive surgery. URGENT SITUATION Dr. Kochhar emphasizes the importance of seeing a physician immediately if you have symptoms of facial paralysis. "For the facial nerve, this is the equivalent of having a heart attack," he says. The first step is to determine the cause. This may involve diagnostic imaging such as an MRI, but, says Dr. Kochhar, "it's really the physical examination that's critical" for reaching a diagnosis and treatment plan. Once the cause of the paralysis is determined, it may mean surgery to remove a tumor that's damaging the facial nerve. Often this involves a team approach to treatment. Dr. Kochhar says he is very fortunate to work with an incredible group of specialists at PNI: "Patients are able to one-stop shop and have all their needs met by experts in the field." He continues: "When a patient visits me, they're usually thinking only about aesthetics and how their face looks. However, one of the most important things to address with facial paralysis is the eye not closing properly. That makes patients more susceptible to infection and even blindness." Dr. Kochhar works closely with his ophthalmology colleagues at PNI, who perform eyelid reconstruction to help the patient close the eye completely. For patients who have suffered hearing loss caused by the tumor that damaged their facial nerve, Dr. Kochhar works with neurotologist Courtney Voelker, MD, who fits patients with cochlear implants to restore hearing after the removal of vestibular schwannoma tumors. Dr. Kochhar also notes that patients may not be able to speak clearly or eat normally because of loss of muscle control in the mouth and tongue. PNI has two speech and language pathologists who work with patients with facial paralysis to overcome those limitations. MICROSURGERY MASTERY Dynamic facial reanimation surgery takes four to six hours and involves a medical team of seven people. Dr. Kochhar and his assistant meticulously map out the facial nerves and identify the strongest donor nerve. Dr. Kochhar then harvests tissue from the patient's inner thigh, including its nerves and blood vessels, and attaches it to ones in the face using a special microscope. The placement of the muscle requires his expert judgment so the movement of the new "smile" matches the unaffected side. Patience is crucial, as it takes several months for results to become evident. "Patients won't get movement until about four to six months after surgery, and they have to learn how to smile again," says Dr. Kochhar. To activate the new muscle, patients must use the masseter (chewing muscle) nerve that was rerouted to supply the transplanted gracilis muscle. While it's awkward at first to clench their teeth to make a smile, most patients say it becomes second nature over time. RESTORED QUALITY OF LIFE Dr. Kochhar says his highest priority is to improve his patients' quality of life, particularly given how common it is for patients with facial paralysis to suffer from anxiety and depression. When his patients return to see him, excited to share their new smile, he knows he has made a difference. "While I can't return their old smile exactly as it was," he says, "I do my best to give every patient a new one that will help make them whole again." Together with the team at PNI, Dr. Kochhar is giving patients their quality of life back, one smile at a time. To learn more about the facial nerve program, visit www.pacificneuroscienceinstitute.org Dr. Amit Kochhar

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