At age 4, a child who had been born with a large hemangioma of the left side of the face was scheduled for surgery. The hemangioma had grown rapidly during infancy, leading to congestive heart failure (treated with digitalis and diuretics).
The plastic and reconstructive surgeon discussed doing a first-stage skin resection and reassured the patient’s parents that the surgery would go well. The informed consent signed by the surgeon and the patient’s mother made no mention of the risk of a facial nerve injury, a recognized risk of these procedures.
The hemangioma (8x8 cm, 3cm in depth) was excised with difficulty. In the operative report, the surgeon specifically mentioned attempting to avoid damage to the facial nerve by dissecting across the deep portion of the hemangioma but superficial to the parotid masseteric fascia. The surgery was five hours long with extensive bleeding (1500cc), which obscured the operative field. The patient required two pediatric units of blood intraoperatively.
After surgery, the patient was taken to the ICU, where she remained intubated because of fluid shifts, significant facial edema, and the potential for airway difficulty. She required further transfusions of packed cells and platelets. In the days following the surgery, she remained on mechanical ventilation, and was agitated and edematous. The parents asked many questions but did not find the surgeon adequately accessible. After an extended postoperative stay, the patient returned home (out of state). The surgeon advised the parents that she expected their daughter’s postoperative symptoms of facial weakness and swelling on the left side to resolve with time.
Six months after surgery, the parents were increasingly concerned about the lack of motion of the upper portion of the child’s face. At that time, the child was evaluated for possible repair/reconstruction. The surgeon noted “trace of marginal mandibular function with no facial nerve function in the remainder of the face, representing an injury to the main or peripheral branch of the facial nerve.” An EMG showed minimal remaining facial nerve function on the left.
During the subsequent repair, the left facial nerve was identified in the scar from the prior surgery and was noted to be involved in the hemangioma. Nearly a year after the first operation, no significant muscular function had returned to the left side of the child’s face.