Eyelid Surgery in Facial Palsy
Eyelid and Brow Surgery in Facial Palsy
The surgical management of the patient with a facial palsy has a number of indications and goals:
- To prevent or manage corneal exposure
- To correct lower eyelid ectropion
- To manage brow ptosis
- To manage chronic epiphora or overflow tearing (watering or watery eye)
A number of other surgical and non-surgical specialties may be involved in the care of the patient with a facial palsy, e.g. an ENT (ear, nose and throat) surgeon, a neurosurgeon, a neurologist, a plastic surgeon, a physician. It is essential that effective communication exist between such doctors for the optimal care of the patient with a facial palsy. The ophthalmic surgeon must be made aware of the prognosis for recovery of facial nerve function, e.g. following the removal of an acoustic neuroma, and of any plans for surgery by other colleagues, e.g. facial reanimation surgery.
The impact of a facial palsy on a patient is not under-estimated.
Eyelid and Brow Surgery in Facial Palsy
The main objective is to protect the cornea (the clear “window” at the front of the eye). Sight threatening complications of a facial palsy relate to a condition referred to as corneal exposure (exposure keratopathy) in which the front of the eye, which is normally lubricated and protected by blinking of the eyelids, can become dry, scarred and even ulcerated when the eyelids are unable to close.
The problems of exposure of the cornea are even more serious in a patient who has lost corneal sensation. Such patients are unaware when the eye is dry, or ulcerated, or has sustained any damage from simple rubbing of the eye, or exposed during sleep if the eyelids are not fully closed. Often a red eye in these situations will alert the patient to the presence of corneal exposure. If the eye becomes red then you should consult your surgeon as soon as possible.
A number of relatively simple medical treatments can be used, particularly for a limited time in the patient who has a good prognosis for the recovery of facial nerve function and who has no major risk factors for the development of exposure keratopathy.
These treatments include:
- The use of frequent preservative free topical lubricants (artificial tears e.g. Hylotears)
- The avoidance of eye irritants e.g. dusty smokey astmospheres
- The use of spectacle side shields or moisture chamber goggles
- Closing the eye at night with Micropore tape
- Botulinum toxin injections to the upper eyelid to induce a temporary protective ptosis
- The application of external eyelid weights
The most common ophthalmic treatment for facial palsy is the use of frequent artificial tears or ointments. These should be used at least on an hourly basis during the day and should be preservative free to avoid corneal toxicity from such frequent exposure to preservatives. The use of preservative free lubricant ointment e.g. Lacrilube, provides more efficient corneal protection than drops with a much reduced frequency of instillation but unfortunately with more blurring of vision.
Patients should avoid ocular irritants wherever possible, e.g. tobacco smoke, dusty environments.
Most patients do not like to use moisture chamber goggles or plastic wrap occlusive dressings but spectacle side shields are relatively unobtrusive and can be well tolerated.
The upper eyelid can be taped closed over the eye at night using Micropore tape but it is essential to ensure that the eye is fully closed to prevent further damage to the cornea from contact with the tape.
Botulinum toxin can be injected into the levator muscle in the upper eyelid to induce a ptosis for a patient with a temporary facial palsy. This is, however, expensive and commits the patient to monovision (seeing with one eye) for a period of 8–12 weeks before spontaneous recovery occurs. Some patients can develop problems with fusion and suffer diplopia (double vision) following the use of botulinum toxin. In addition, as the superior rectus muscle can be weakened, the protective Bell’s phenomenon may be adversely affected, creating more problems with exposure of the cornea during the recovery phase.
An external eyelid weight may be applied to the upper eyelid with a tissue adhesive. The weight is flesh coloured to make it less conspicuous. Such weights are useful for a temporary facial palsy but can also be used for a trial period before subjecting a patient to an upper eyelid gold weight implant.
In patients with decreased tear production who cannot be managed adequately with artificial tears and ointments alone, punctal occlusion can be beneficial. This can be achieved temporarily with the use of silicone punctal plugs. If these are tolerated without secondary overflow tearing, permanent punctal occlusion can be performed surgically under local anaesthesia.
Temporary suture tarsorrhaphy
A temporary suture tarsorrhapy can be used for the patient who has an acute facial palsy and who is unsuitable to undergo any other procedure or who is unable to instil lubricant drops or ointment. A 4/0 nylon suture is passed through the margin of the upper and lower eyelids and tied over silicone or rubber bolsters. The suture (stitch) can be tied with a slipknot enabling the tarsorrhapy to be opened to examine the eye.
A lateral tarsorrhaphy has been the time-honoured minor surgical method of providing adequate corneal protection in the management of the patient with a facial palsy. This involves the stitching together of the outer aspects of the eyelids, which then heal together. The procedure can be reversed.
In this procedure the inner aspect of the eyelids are fused together surgically. This procedure is often used in addition to a lateral tarsorrhaphy to further improve corneal protection in a patient with a facial palsy. It also helps to prevent the development of a lower lid ectropion in the inner third of the eyelid.
Müllerectomy and levator aponeurosis recession
The removal of Müller’s muscle and a gentle recession of the upper eyelid retractors may benefit the patient with a chronic facial palsy who has upper eyelid retraction. These procedures are undertaken on the inside of the upper eyelid to lower the eyelid thereby reducing the area of the cornea that is exposed.
Gold (or platinum) weight insertion
Gold (or platinum) weight implantation is a simple and useful procedure for the patient with a chronic facial palsy. It is very useful in the patient who has undergone a lateral tarsorrhaphy and is dissatisfied with the cosmetic appearance, and wants the procedure to be reversed. The success of gold (or platinum) weight implantation depends on very careful patient selection. The procedure can improve voluntary eyelid closure but it does not restore a normal reflex blink.
The insertion of a gold weight into the upper eyelid:
The correction of lower eyelid ectropion
The management of greater degrees of ectropion in a patient with a facial palsy depends on an evaluation of the causes of the ectropion, e.g. chronic overflow tearing may lead to cicatricial (scarring) changes in the lower eyelid that may require a skin graft procedure.
In patients who are poor candidates for a facial reanimation procedure by a specialist plastic surgeon, the mid-face ptosis may be addressed either with a static sling using fascia lata from the thigh to pull the lip and face upward toward the bone of the zygomatic arch in the outer cheek area, or with a sub-orbicularis oculi fat (SOOF) or mid-face lift. These procedures help to relieve the downward traction of the sagging face from the lower eyelid.
The correction of chronic watering or overflow tearing of the eye
In spite of the successful correction of a lower eyelid ectropion, and the improvement of eyelid closure and corneal exposure, the patient may still experience chronic watering of the eye due to a poor lacrimal pump mechanism. In such cases it may be necessary to resort to an endoscopic conjunctivo-dacryocystorhinostomy (CDCR) with placement of a Lester Jones tube.
The management of brow ptosis
A unilateral brow ptosis may be severe enough to cause impairment of the superior visual field as well as a cosmetic deformity (Figure 7.25). It can cause a pseudo-blepharoptosis (an apparent but not true droop of the upper eyelid), and may lead to a secondary misdirection of the upper eyelid lashes which can irritate the eye.
Although a number of different surgical approaches for the management of a brow ptosis complicating a facial palsy have been described, the preferred approaches are:
- A direct brow lift
- An endoscopic brow lift
A direct brow lift
A direct brow lift is a simple but effective procedure to correct a unilateral brow ptosis. It can be combined, if necessary, with an upper eyelid blepharoplasty. If a blepharoplasty is deemed to be necessary, the brow lift should be performed first. The blepharoplasty should be very conservative to avoid aggravating any incomplete upper eyelid closure.
Endoscopic brow lift
An endoscopic brow lift in the management of a unilateral brow ptosis avoids visible scars but is less likely to provide a long lasting result.
Aberrant reinnervation of the facial nerve
Aberrant reinnervation can occur following recovery from a facial palsy. This refers to the “mis-wiring” of branches of the facial nerve, with branches supplying the wrong muscles. The degree of disability from aberrant reinnervation is variable. Some patients experience complete eyelid closure when using the perioral (mouth) muscles. Such patients may be treated with botulinum toxin injections to the orbicularis oculi muscles (the eyelid muscle responsible for reflex and voluntary eyelid closure), but such treatment can worsen incomplete eyelid closure and increase the need for frequent topical lubricants.
Direct neurotization of the cornea using the contralateral supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve is a procedure that may restore some corneal sensation to selected patients with a unilateral facial palsy and an anesthetic cornea.
Eyelid and Brow Surgery in Facial Palsy
You will visit the clinic to have a preoperative consultation with your surgeon. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire, providing information about:
- Your specific aims
- Your current and past general health
- Any previous eye, eyelid, brow or facial surgery or treatments including refractive surgery or laser eye surgery
- Any past dermatology history e.g. cold sores, eczema, rosacea, skin cancer
- Any history of a dry eye problem
- Any contact lens wear
- Any previous non-surgical treatments e.g. Botox injections
- Any allergies
- Any medications you take (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements)
- Any history of smoking
It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email us digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.
- You will have your blood pressure checked by the nurses. You may also be required to have a physical examination of your heart and lungs by the anaesthetist to make sure it is safe for you to have a general anaesthetic if this is required in your case. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.
- The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use.
- Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic surgery can be planned as carefully as possible. The information is treated confidentially. If you are unsure of the names of any medications, bring them with you.
- You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.
- Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) are examined as well as the eyelids themselves.
- The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.
Eyelid and Brow Surgery in Facial Palsy
After surgery, depending on the surgical procedure which has been undertaken, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.
You will be asked to clean the eyelid/brow wounds very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended.
A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Xailin gel (or Theoloz Duo drops, Hyabak drops or Hylotears), and Xailin Night ointment (or Lacrilube or Vitapos ointment at bedtime).
You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.
Conscious sedation, also known as “twilight anaesthesia”, is a type of anaesthesia which is preferred by many patients for most of my surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.
Click here to watch a video of a patient describing her experience of “twilight anaesthesia”. She underwent a bilateral upper lid blepharoplasty and endobrow lift at the clinic.
Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drug is given through that. This is Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any “grogginess.” This type of anaesthesia has been used safely and successfully for our surgical procedures for over 20 years.