What is eyelid surgery for facial paralysis?

In patients with facial paralysis, there can be varying degrees of eye closure problems.  The condition is know as lagophthalmos, and it can be quite serious and cosmetically problematic.  Inability close the eyelid can result in significant problems, including persistent dry eye, corneal scarring (keratitis), persistent tearing, eye pain, and loss of vision.  This is perhaps the most devastating consequence of facial paralysis.  Treatment is initially directed at managing lagophthalmos, if severe enough to cause persistent symptoms.

Treatment to correct this problem consists of a number of interventions that are designed to help the eyelids achieve better closure and protect the eye.  An evaluation by an experienced ophthalmologist is a critical first step in investigating the level of damage sustained to the eye itself.  Interventions almost always begin with application of eye lubricant 2-3 times daily and frequent moistening drops using over-the-counter artificial tears.  Taping of the lower eyelid may also be required at nighttime when sleeping.

Beyond conservative interventions, eyelid surgery can offer permanent relief of lagophthalmos symptoms.  It is important to understand that lagophthalmos results from a combination of upper and lower eyelid dysfunction.  In facial paralysis, the lower eyelid sinks with gravity and increases the distance to closure the upper eyelid must achieve.  The upper eyelid also lacks forceful closure and does not always drop far enough to protect the cornea.  Eyelid surgery seeks to correct this problem by allowing the upper eyelid to come down further and the lower eyelid to rise up.

Before and after photos of woman following placement of upper eyelid weight for facial paralysis.

How is eyelid surgery for facial paralysis performed?

There are several technique for upper eyelid correction:

Preop assessment of upper eyelid weight size needed.Gold or platinum weight insertion:  an incision is placed in the upper eyelid crease, and the cartilaginous portion of the eyelid is identified.  A thin gold or platinum weight is then inserted into this space and centered over the cornea.  It is secured with sutures to prevent migration, and the incision is closed.  The amount of weight to be used is determined preoperatively by applying small weights to the upper eyelid.

Diagram of upper eyelid weight insertion.
Palpebral spring placement:  an incision is placed in the upper eyelid crease, and a specially-designed spring is inserted.  A tunnel is created for placement of the second limb of the spring near the eyebrow.  The spring is the secured in place with sutures and tested during surgery with the patient awake.  Blinking is performed, and the spring adjusted as necessary.
Diagram of palpebral spring insertion for eyelid paralysis.

Levator palpebrae lengthening:  an incision in the upper eyelid crease is placed, and the levator mechanism of the upper eyelid (responsible for elevating the upper eyelid) is identified.  An opening in the mechanism is made.  A piece of fascia graft is then taken from the temple region with dimensions corresponding to the degree of upper eyelid asymmetry (determined preoperatively).

Lower eyelid correction can also be achieved in a number of ways:

Lower eyelid tendon sling:  small incisions are placed along the lower eyelid, and a small tunnel is created at the margin.  A thin tendon graft is obtained, most commonly from the wrist, and transferred to the lower eyelid incisions.  The tendon is then looped around the inner eyelid ligament (canthus).  The tendon is passed through the tunnel, then anchored to the upper and outer portion of the bony orbit.

Lower eyelid tendon sling for facial paralysis lagophthalmos correction.
Modified tarsorrhaphy:  small incisions are placed along the outer 4-6 mm of the upper and lower eyelids at the margin.  The incisions are placed asymmetrically in order to advance the lower eyelid out towards the corner more than the upper eyelid.  The incisions are closed with absorbable sutures.

Tarsal wedge resection:  also known as lower lid shortening, this involves excising a full-thickness segment of the outer lower eyelid including skin, conjunctivae, and cartilage.  The wedge is then closed, tightening up the lower eyelid and slightly elevating it.

Tarsal wedge resection for lagophthalmos in facial paralysis.

Other options are available for both upper and lower eyelid reconstruction in the setting of facial paralysis.  Dr. Panossian can go over individual options and tailor the treatment plan accordingly.

 

What is the recovery for eyelid surgery?

Depending upon the set of surgical interventions being performed, surgery frequently requires general anesthesia and can take between 1-4 hours to complete.  This is most often performed on an outpatient basis.  Stitches will need to be removed between 5-7 days after surgery.

Swelling of the eyelids can occur, but typically resolves over the first week.  Bruising is not always present, but it will also improve during the same time period.  Activity is restricted during the first 4 weeks to light walking and stationary activities.  Heavy lifting, contact sports, and aerobic exercises are to be avoided during this time.  Most adult patients elect to take approximately 3-7 days off from work.  During this time, make up can be used to mask any bruising. Scar management is started at 3-4 weeks postop to ensure excellent scar healing.

What are the risks and complications of eyelid surgery for facial paralysis?

Complications are rare with eyelid surgery for facial paralysis.  Standard risks associated with all surgeries apply.  These can include bleeding (hematoma), infection, or adverse reactions to anesthesia.  In adults, uncontrolled diabetes and smoking may affect healing and overall results.  As a dynamic procedure, there is always a risk of minor asymmetry and need for revision.

To minimize your risk, pay close attention to your surgeon’s instructions before and after surgery.  Dr. Panossian's staff is available at all times to clarify any pre- or postoperative instructions that you were given.

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