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Eyelid Reanimation in Patients With Facial Paralysis


Prompt attention to the ophthalmic manifestations of facial nerve paralysis is crucial to the care of affected patients. Loss of facial nerve function causes numerous functional and cosmetic deficits in the periocular region. These include poor eyelid closure with an increased palpebral fissure height, lower eyelid ectropion causing limited lacrimal pump function, decreased meibomian gland function and rapid evaporation of tears, decreased lacrimation from loss of parasympathetic tone, and descent of the brow with secondary hooding of the visual axis.

Symptoms can range from mild discomfort to severe dryness with corneal ulceration and scarring to corneal perforation with loss of the involved eye. Greater degree and duration of facial nerve dysfunction is the most important risk factor for significant ocular damage, but other features such as concurrent trigeminal nerve involvement, poor Bell phenomenon, and increased age or greater tissue laxity worsen the prognosis for the eye.

We have chosen to include two routinely performed staples of eyelid “reanimation” (upper eyelid weight and lower eyelid lateral tarsal strip) and one procedure that we have found to be of great value in the management of facial nerve paralysis (the tarsoconjunctival onlay flap). The latter can be viewed as a type of tarsorrhaphy, with greater cosmesis and reversibility, with potentially less limitation of peripheral vision.

Other important procedures often performed on patients with facial paralysis, such as brow-lifting procedures, blepharoplasty, tarsorrhaphy, and lower eyelid spacer graft, are briefly mentioned in the discussion.

Upper Eyelid Weight

Upper eyelid closure is more important than lower eyelid position in preserving corneal lubrication. Two common techniques that are employed to treat a paralyzed upper eyelid are the upper eyelid weight and the palpebral spring. Palpebral springs produce a more rapid closure than a weight, but they typically drop the upper lid margin and have problems with extrusion and migration as well as magnetic resonance imaging (MRI) incompatibility. Therefore, placement of an upper eyelid weight, which allows the paralyzed lid to close with gravity, continues to be commonly performed due to its relative surgical simplicity, high success rate, low complication rate, and cosmetic acceptability. Gold is the most commonly placed weight material; but a cosmetically visible lump, extrusion, inflammation, capsule formation, and gold allergy have led to platinum chains being inserted in many cases. The pretarsal weight implantation technique is described in detail in this chapter.

Key Operative Learning Points

  • 1.

    Placement of the weight should be as inferior and medial as possible and fixed to the tarsal plate to prevent migration.

  • 2.

    Dissection through the orbicularis oculi muscle should be straight down from incision to superior tarsal border so that the muscle can be easily and anatomically closed over the implant.

  • 3.

    Pretarsal placement of the weight will offer the best closure but might be more cosmetically noticeable than other placement techniques.

Preoperative Period

History

  • Frequent irritation or foreign body sensation?

  • Prognosis for return of facial nerve function, if known?

  • Previous eyelid surgery?

Physical Examination

  • Degree of upper eyelid closure during reflex blink and with forced closure? How much lagophthalmos is present?

  • Corneal sensation impaired?

  • Conjunctiva injected?

  • Corneal surface examination: fluorescein uptake using cobalt blue light, especially inferiorly?

  • Areas of corneal thinning, stromal haze, neovascularization, or scarring?

Imaging

None necessary

Indications

  • 1.

    Significant lagophthalmos with signs or symptoms of corneal desiccation

  • 2.

    Expected duration of facial nerve paralysis of at least several weeks

Contraindications

  • 1.

    Known gold allergy would indicate placement of an alternate implant material.

  • 2.

    Restrictive or cicatricial cause of lagophthalmos

Preoperative Preparation

The appropriate weight is chosen by affixing a sizer weight, using double-sided tape or mastisol, to the pretarsal eyelid skin, waiting 10 minutes for the patient to get accustomed to the weight and then observing the eyelid position and movement. Good closure with minimal lagophthalmos and a maximum of 1 to 2 mm of ptosis indicates the appropriate weight selection.

Operative Period

Anesthesia

Local anesthetic or monitored anesthesia care with local anesthetic

Positioning

Supine

Perioperative Antibiotic Prophylaxis

None

Monitoring

None unless under monitored anesthesia care (MAC)

Instruments and Equipment to Have Available

  • Castroviejo needle drivers

  • Westcott or spring-loaded iris scissors

  • Small toothed forceps for gentle tissue handling

  • Small double-skin hooks

  • Appropriate suture

  • Gold or platinum plate

Key Anatomic Landmarks

  • 1.

    The superior border of the tarsus is indicated by a vascular arcade often visible beneath the levator fibers and on the surface of Muller muscle.

  • 2.

    The lash follicles in the skin will indicate the approaching eyelid margin as dissection descends along the tarsus.

  • 3.

    When dissecting in the pretarsal region of the eyelid, only the skin, orbicularis, and levator aponeurosis fibers are encountered before reaching the tarsal plate.

Prerequisite Skills

  • 1.

    Basic tissue handling and dissection skills

  • 2.

    Familiarity with the extraocular anatomy

Operative Risks

  • 1.

    Dissection superior to the tarsal plate could result in recession of the levator tendon causing ptosis and bleeding from the peripheral eyelid vascular arcade.

  • 2.

    Placing the implant-fixing sutures full thickness through the eyelid could cause significant corneal damage postoperatively; in addition, failure to lift the tarsal plate off the globe surface when placing these sutures risks entering the cornea with the suture needle.

Surgical Technique

  • 1.

    The upper eyelid crease is marked across the central and medial upper eyelid. The placement of the weight will be centered over the medial limbus (border of the iris) ( Fig. 179.1A ). In a case of a concomitant sixth cranial nerve palsy, placement should be as far medial as possible.

    Fig. 179.1, A, Gold weights are tried as external lid loads preoperatively. B, Double-action scissors are used to sharply dissect a pocket to the tarsal plate noted as a white plane. C, Further dissection divides the orbicularis muscle and levator aponeurosis. The lowest point of dissection is 2 mm from the lash line, often noted surgically as the position of the vascular arcade. D, The gold weight is centered at the medial and central third of the lid to improve coverage medially. Three-point fixation is necessary to avoid extrusion, and the levator and orbicularis are closed with 6-0 absorbable suture.

  • 2.

    The upper eyelid is injected with 1% lidocaine with 1:100,000 epinephrine.

  • 3.

    A 2- to 2.5-cm incision is made with a number 15 blade in the marked crease of the upper eyelid. This incision line is generally 8 to 10 mm from the margin of the upper lid.

  • 4.

    Sharp dissection is carried through the orbicularis oculi, straight down to the surface of the tarsal plate. The tarsal plate is contacted near its superior border (see Fig. 179.1B ).

  • 5.

    A pretarsal pocket is then created, which extends inferiorly to the beginning of the lash follicles, and as medial as the tarsus extends (see Figs. 179.1C and 179.2A ).

    Fig. 179.2, A, Pretarsal pocket has been created, which extends inferiorly to the lash follicles and medially to the edge of the tarsus. B, Implant (in this case, platinum) is placed into the pretarsal pocket as inferiorly as possible, centered over the medial limbus and secured with 8-0 nylon sutures, partial-thickness through the tarsus. C, Skin closure using 7-0 chromic sutures, after closure of orbicularis over the implant with 6-0 Vicryl.

  • 6.

    The implanted weight is placed into the pocket, ideally centered over the medial limbus and as inferior as possible, with the two suture holes inferior and the single central suture hole superior. The implant is secured using 8-0 nylon sutures, placed partial thickness through the tarsal plate (see Fig. 179.2B ). To place these partial-thickness sutures, the lid is elevated off the surface of the globe, and after placement, the underside of the upper eyelid is inspected to ensure that the needle has not been passed full thickness through the conjunctiva.

  • 7.

    The orbicularis oculi muscle is then closed with buried interrupted 6-0 Vicryl sutures.

  • 8.

    The skin layer is then closed using 7-0 chromic sutures or similar (see Fig. 179.1D and 179.2C ).

Common Errors in Technique

  • 1.

    Failure to place the weight centered over the medial limbus thereby sacrificing some eyelid closure

  • 2.

    Failure to properly fix the weight to the tarsal plate

  • 3.

    Failure to close the orbicularis layer over the weight to prevent extrusion

  • 4.

    Suturing deeper tissue such as the septum or the levator in the attempt to close orbicularis, thereby shortening the eyelid and creating cicatricial lagophthalmos

Postoperative Period

Postoperative Management

  • 1.

    Ophthalmic antibiotic ointment is applied 3 to 4 times per day to the suture line.

  • 2.

    If removable sutures are used, they are removed in 7 to 10 days.

  • 3.

    Even if dissolvable sutures are used, the patient should be seen within 2 weeks to monitor the condition of the corneal and eyelid closure.

Complications

  • 1.

    Oversized or undersized weight

  • 2.

    Implant migration and extrusion

  • 3.

    Inflammatory reaction or allergy to the implant

  • 4.

    Pressure-induced astigmatism

Alternative Management

  • 1.

    In some cases with reasonably good eye closure, lubrication alone or lubrication and lower eyelid surgery might be sufficient.

  • 2.

    Palpebral springs can be considered.

Lateral Tarsal Strip

Loss of tone in the orbicularis oculi muscle causes laxity and often ectropion in the lower eyelid, distracting the eyelid from the globe, allowing tears to pool in the inferior conjunctival cul de sac, blurring vision, worsening the lacrimal pump function, and allowing rapid evaporation of tears.

In many cases, a lateral tarsal strip procedure to shorten and tighten the lower eyelid can be extremely helpful in reducing lower eyelid laxity and improving lower eyelid apposition to the globe. Importantly, this procedure need not be reversed in case of facial nerve recovery.

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