Pediatric plastic surgery: Interventions for Moebius syndrome

A common issue for some infants at birth is facial paralysis. This condition, whether full or partial paralysis, creates a lack of movement in the face, leading to difficulties for children in expressing emotion, speaking and performing other necessary facial movements.

Moebius syndrome, while rare, is one of the most common varieties of facial paralysis in children. This congenital condition causes full or partial paralysis of the face and can be damaging to the social development of children as they grow.

These children can potentially not be properly socialized or ostracized from social groups because they are unable to properly communicate emotion through facial expressions and may have imbalances in facial movements. However, this condition can be treated with the right interventions through plastic surgery, resulting in many patients regaining a higher level of control of their facial movements when following the right protocols.

If you are interested in learning more about Moebius syndrome and the treatment options available for patients, we're here to help. ASPS Member Surgeon Andre Panossian, MD, has dedicated time to the subspecialty of treating facial paralysis, including Moebius syndrome. We spoke with him to gather his insights around this topic, his thoughts on surgical interventions and best practices for parents of children with Moebius syndrome to encourage the best possible results.

A brief examination of Moebius syndrome

Moebius syndrome is a rare condition that is present at birth. It affects approximately one in 200,000-300,000 individuals, without a true identified genetic cause.

"Moebius syndrome is a congenital condition that has features of cranial nerve 6 and 7 paralysis almost universally, and almost universally bilateral – on both sides of the face," said Dr. Panossian. "The net result of that is a complete facial paralysis on both sides of the face, also known as mask-like facial features, which basically means no movement of the face."

Patients with Moebius syndrome who are not properly treated are unable to move their face because of these nerve issues, creating what has been described as a "mask-like" appearance that does not properly express emotion. This can also be coupled with other issues, such as being cross-eyed, due to the nerve paralysis.

"Because of the cranial nerve 6 deficiency, the eye does not pull outwards," said Dr. Panossian. "Kids with this problem can't gaze out to the side. Oftentimes, they get cross-eyed with this and need an ophthalmologist to help address the problem."

Children with Moebius syndrome do not experience any other health problems or disabilities, although many may be considered to be developmentally delayed later in life. However, there is some anecdotal data that suggests the delays can potentially be psychological in nature rather than related to Moebius syndrome.

"What ends up happening is that some of those kids are delayed a little bit, as they're treated as if they have lesser intelligence growing up," said Dr. Panossian. "It's almost this psychological disconnect from what you're seeing. This person isn't smiling when they should be, so they must be delayed."

Surgical interventions for Moebius syndrome

Fortunately, there are surgical interventions for treating patients with Moebius syndrome that can offer substantial results in regaining movement of the face. The two most popular options both involve the reanimation of the smile, which is a crucial component of facial expression and social development.

These options utilize different parts of the body to recreate the smile, with one using the gracilis muscle from the thigh and the other using the temporalis muscle along the side of the face. Which technique is used is often determined by the surgeon, depending on the method they are most comfortable with.

Dr. Panossian is a leader in the use of the temporalis muscle to reanimate the smile, performing innovative procedures known as the "temporalis smile lift."

"Basically, you slide the temporalis muscle into the corner of the mouth, so when children go to take a bite of something, it lifts the corner of the mouth into a smile," said Dr. Panossian. "This can be retaught to children as a method of smiling. The brain is very adept at repurposing a muscle from one function and one nerve to a completely different nerve and function."

One advantage of using the temporalis muscle in the face is surgeons can perform the procedure in one surgery.

"I'll typically do the temporalis smile lift because I can do both sides at the same time," said Dr. Panossian. "You usually can't do this with the other option, which is to use a gracilis muscle."

Additionally, this type of procedure is adjustable, allowing surgeons to tighten the muscle if needed later on to provide more balance and function in the face.

There is a period of recovery for patients after a temporalis smile lift before the final results are visibly seen and physically felt.

"Once time has passed and the scar tissue has softened and the muscle is able to move in the cheek, we'll start to see improvements year over year," said Dr. Panossian. "With time and with the patient engaging in the exercises that they need to do, they're able to strengthen that muscle as with any other muscle in the body; patients are able to get more movement out of the cheek."

Moebius syndrome may be a rare condition, but this congenital disorder causes full or partial facial paralysis in children and needs to be urgently addressed to promote proper social development. Plastic surgeons can effectively counter this facial paralysis and give children back their smiles.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.