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Permanent Surgical Injury Case Settled for More Than $1 Million

Prior to any surgery, a patient and their family members always want to know what risks are involved in the procedure.

The patient depends on the surgeon to offer a step-by-step description of the procedure and to discuss any and all risks involved.

But the parents of a young child under going surgery to remove a very large hemangioma on her face were never told that facial paralysis was one of the risks of the surgery. As a result of facial nerve damage during the procedure, the child was left with a profound left facial paralysis.

What’s more, the surgeon was not available to the parents immediately following the surgery to discuss any complications that may have arisen and did not schedule any follow-up appointments.

The child’s parents sued the surgeon, alleging negligent performance of surgery, resulting in the transection of the facial nerve, and failure to intervene within the critical postoperative period. Through mediation, the case was resolved for more than $1 million.

At age 5, the 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).

Hemangiomas are benign tumors made of blood vessels. They are frequently found on the skin of the head or neck and grow and change during the first few months of life. Annually, about 80,000 children in the United States are diagnosed with hemangioma, and about 12 percent require treatment. Complications of hemangioma include permanent scarring, ulceration, bleeding, loss of vision, airway obstruction, congestive heart failure and, very rarely, death.

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, several layers beneath the skin. The surgery was five hours long with extensive bleeding, 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 swollen. The parents asked many questions but did not find the surgeon adequately accessible.

After an extended postoperative stay, the patient returned home to another city. 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.

The child’s parents had a strong case for medical malpractice based on the following factors:

• The operative note signed by the surgeon is silent regarding the identification and isolation of the facial nerve. Great care must be exercised during surgery in this area to avoid damage to that nerve and to minimize the effects if it is damaged. The surgeon should have documented the routines and the fact that they were followed carefully to prevent or minimize injury.
• Blood loss was not recorded in the operative report. It is customary to record estimated blood loss in the operative report, particularly if the blood loss was large.
• The patient was lost to follow-up. Postoperative monitoring seemed to stop after the patient was discharged, and the facial nerve damage was not identified for several months. The attending surgeon should address any complications with the patient and family in a direct and forthright manner, to afford the optimal opportunity to recover.
• The most serious risks of this procedure were not discussed with the parents, even though the risks are common to this procedure. The parents’ expectations for a successful surgery were very high based on their conversation with the surgeon. They had not anticipated the complication or the prolonged period of intubation that was required following the surgery.
• The surgeon avoided the parents in the immediate postoperative period when intervention could perhaps have improved their daughter’s outcome. The first evaluation for possible repair/reconstruction was performed six months later – too late to expect successful recovery of nerve function.

For more on patient safety issues, see the library of articles by Daytona Beach medical malpractice attorney.




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