Giving a smile back: reflections on a craniofacial fellowship in Canada

A smile is something most of us never think about. It happens before we decide it should, a reflex of connection, older than language. So when one half of the face stops moving, the loss goes far beyond the physical. Patients with facial palsy tell you they avoid photographs, cover their mouth when they laugh, and slowly withdraw from the moments that used to bring them joy. The asymmetry is visible to everyone; the isolation it causes is visible to almost no one.

I spent the past six months confronting that problem daily, on fellowship at Vancouver General Hospital, one of North America's high-volume craniomaxillofacial centres, training in craniofacial surgery and working alongside Dr Nancy Van Laeken and Dr Asim Bashir in facial palsy surgery. What I saw there reshaped how I think about the face, and about what our specialty can offer.

Early in the fellowship, a relatively young woman came to us seven months after surgery for an acoustic neuroma, a benign tumour of the hearing nerve. The tumour was gone, but the facial nerve on that side had not recovered. Her palsy was complete: no movement, no expression, no smile on one side of her face.

Seven months is a critical window. Wait too long and the muscles of the face lose their ability to be rescued. So we performed a cross-facial nerve graft, borrowing the sural nerve from her leg and using it as a living cable, tunnelled across the face, to carry signals from the healthy side to the paralysed one. It is meticulous work under the microscope, joining nerves finer than a thread. And then you wait, because nerves regrow at roughly a millimetre a day.

Because the case was done early in my fellowship, I had a privileged fellowship surgeons rarely get, I watched the reinnervation unfold. Over the months that followed, the first flickers of movement returned, then strengthened, month on month. By the time I left Vancouver, her smile had recovered considerably from where she started and was well on its way to a normal smile, and she was thrilled with every new movement she gained. The change in her outlook was as dramatic as the change in her face, and I have no doubt that a full smile is not far away. Plastic surgeons are, by nature, problem solvers, and there is a quiet satisfaction in solving a hard one. But to watch a solution transform how someone carries themselves in the world, that is the true reward of this work.

Her operation is one point on a wide spectrum. Depending on the pattern and duration of the palsy, we now have an entire toolkit: botulinum toxin to rebalance overactive muscles, selective neurectomy to refine unwanted movements, nerve grafts and muscle transfers to reanimate a paralysed face, and facelift techniques to restore symmetry and support to tissues that have lost theirs. No two faces fail the same way, so no two reconstructions are the same. The skill lies in matching the technique to the person.

That matching is learned, not read. The quality of surgery I witnessed in Canada and the United States was exceptional, but what stayed with me most was the generosity of the surgeons teaching it. My time with Dr Van Laeken and Dr Bashir was immersive fellowship training in the fullest sense: months in their theatres, operating, absorbing not just techniques but judgement, the why behind every decision.

Alongside that, I undertook briefer observerships with some of the world's leading facial aesthetic surgeons, Dr Ozan Sozer, Dr Tim Martin, Dr Rick Warren, Dr Ben Talei and Dr Guy Massry among them, who gave their time just as freely. An observership of days sounds slight next to a fellowship of months, but with extensive training already behind you, it becomes something powerful. You are no longer there to learn a whole operation; you are there for the nuance, a particular way of handling tissue, a subtle refinement of technique, a detail honed over an entire career. Those details are exactly what a trained eye can take home and use.

Together, that generosity compresses years of learning into months, and it is the reason dedicated international fellowship experience matters: surgeons earlier in their careers can absorb the judgement of masters in the field and deliver the best outcomes to their own patients far sooner than they otherwise could.

It also reinforced something I have long believed. The face is one integrated structure. Craniofacial surgery, facial palsy, head and neck reconstruction and facial aesthetic surgery are not separate disciplines, they are the same discipline viewed from different angles. My years dedicated to reconstructive surgery are precisely what give me a nuanced, anatomically precise approach to facial aesthetic surgery. Whether the goal is to restore a smile after nerve injury or to rejuvenate an ageing face, the anatomy is the same, and it rewards the surgeon who knows it deeply.