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  • Management of the Facial Nerve Palsy Patient: Update and Pearls

    Oculoplastics/Orbit
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    Facial nerve palsy is a commonly encountered problem in ophthalmology practice. The severity of symptoms affecting the eye can vary significantly. Some patients will require only treatment with occasional artificial tears, whereas others will require multiple surgeries to address chronic corneal exposure.

    When assessing a patient with facial nerve palsy, the clinician should consider the underlying etiology. A patient who has undergone a parotidectomy with transection of the facial nerve will require more rehabilitation than a patient with idiopathic Bell's palsy, who will most likely recover full function. The House-Brackman grading system (Table 1) can be helpful in communicating the severity of facial nerve palsy to other physicians and to follow the course of an individual patient.

    Examination

    On physical examination, it is important to assess for corneal changes, incomplete blink, lagophthalmos, Bell's phenomenon, lower lid laxity and tone, and brow malposition. It is also crucial to evaluate other cranial nerve function, particularly corneal sensation. Patients with both V1 and facial nerve damage are more susceptible to corneal breakdown and perforation. These patients need to be monitored frequently and treated aggressively with lubrication and tarsorrhaphy if corneal decompensation develops.

    Harrison

    Table 1. House-Brackman grading scale for assessing severity of facial palsy.

    If the underlying etiology of the facial palsy is trauma, it is also important to check for signs of aberrant regeneration. One way to check for this is to have the patient puff their cheeks and look for narrowing of the ipsilateral palpebral fissure. This problem can be treated with botulinum toxin A injections to weaken the orbicularis muscle. Another manifestation of aberrant regeneration is "crocodile tears," or tearing with salivation. This also may be treated with botulinum toxin A injections, 5 to 10 units transcutaneously or transconjunctivally into the lacrimal gland.

    The rest of this article will focus on surgical rehabilitation of the periorbital area in patients with facial nerve palsy.

    Browplasty

    For brow ptosis secondary to weakened frontalis muscle function, a direct brow lift can be performed with an incision just above the brow hairs. Alternatively, a unilateral midforehead lift can be performed if there are deep rhytids already present to camouflage the scar. The incision can also be made in the smooth forehead to match a rhytid on the uninvolved side. Internal browpexy with either suture fixation or transblepharoplasty absorbable multipoint fixation device can also address brow ptosis. Finally, endoscopic brow and forehead lifting can be performed in these patients with favorable outcomes.

    Gold Weight Implantation

    Gold weight insertion in the upper lid is used to augment the weakened blink function. The gold weight is inserted via a lid crease incision and can be placed in the pretarsal or prelevator aponeurosis space. While several techniques have been described, the authors prefer to combine this procedure with levator aponeurosis recession and effectively use the gold weight as a spacer between the superior border of the tarsus and the edge of the levator aponeurosis (Figure 1). The presence of the weight in addition to lowering the lid height allow for more complete closure. The placement of the weight at the superior border of the tarsus also results in a better cosmetic result because it is hidden in the normal sulcus of the upper lid (Figure 1). Regardless of where the weight is placed, meticulous suturing of the weight and layered closure of the orbicularis and skin are necessary to prevent extrusion. A trial of lid weights in the clinic preoperatively can help predict what size gold weight will be most effective for the patient. The authors typically add 0.2 gm to the weight determined in clinic (which usually results in a 1.6 gm or 1.8 gm gold weight). We have found that the more superior and posterior placement requires a slightly higher weight than that taped in the pretarsal space in the clinic. This is most likely due to the decreased vertical vector due to the implant positioning. In patients with a good chance for recovery of function, several companies make external skin-tone weights that can be temporarily taped onto the pretarsal eyelid with double-sided tape.

    Harrison
    Figure 1. Pre- and postoperative photographs of a patient with left facial nerve palsy who underwent left upper lid gold weight insertion with levator aponerurosis recession and left lower lid lateral tarsal strip.

    Paralytic Ectropion Repair

    Paralytic ectropion can be addressed in a number of ways. In mild cases, a simple lateral tarsal strip procedure may be adequate. The authors have found that more severe cases may require a posterior lamellar spacer graft to raise the lower lid and a midface lift to support the weight of the paralyzed cheek and recruit anterior lamellar tissue. In this case, a transconjunctival incision is made at the inferior border of the tarsus that connects with the lateral canthal incision that has already been started to perform the tarsal strip. The lower lid retractors are then released, and the inferior orbital rim periosteum is then incised with monopolar cautery, leaving a cuff of periosteum at the arcus marginalis. The suborbicuaris oculi fat, or SOOF, plane is then identified and mobilized. The authors use a 4-0 PDS suture to suspend the SOOF to the cuff of periosteum left at the inferior orbital rim and also to the periosteum of the lateral orbital rim. A spacer graft (eg, allogenic acellular dermis, hard palate, auricular cartilage) is then sutured in place between the inferior edge of tarsus and the cut edge of conjunctiva and the tarsal strip procedure is completed. A Frost suture is placed for 1 to 2 weeks to prevent postoperative cicatricial retraction and recurrent ectropion.

    An alternative procedure to support the lower lid is a fascia lata lower lid sling. Donor or autogenous fascia lata is suspended from the medial and lateral canthi like a hammock to support the lower lid. If there is significant medial canthal tendon laxity, a medial canthopexy in conjunction with a lateral tarsal strip can also be performed to tighten the paralytic lower lid.

    Tarsorrhaphy

    If the patient's main problem is corneal exposure, and cosmesis is not an issue, a lateral tarsorrhaphy can be considered. A temporary tarsorrhaphy can be placed with 2 horizontal mattress 5-0 prolene sutures placed over bolsters to prevent cheese-wiring. Alternatively, a permanent tarsorrhaphy can be placed by splitting the lateral third of the upper and lower lids at the gray line and suturing the posterior lamellae with interrupted 5-0 polyglactic acid sutures and the overlying skin with interrupted 6-0 plain fast-absorbing gut sutures in a layered fashion.

    A medial tarsorrhaphy can also be performed by making a skin incision that starts just above the superior punctum and curves around the medial canthus and ends just under the inferior punctum. A skin-muscle flap is then dissected and is closed in layers covering the caruncle. This addresses medial lagophthalmos while preserving the canalicular system.

    Summary

    Facial nerve paralysis is a potentially sight-threatening disease that ophthalmic surgeons often encounter. The surgeon must address the problem with consideration to both functional and aesthetic outcomes. This usually involves a combination of lifting the ptotic brow, implanting a gold weight to enhance closure, and lower lid tightening to reduce paralytic ectropion. Tarsorrhaphy may be performed temporarily or permanently to offer more protection to the cornea.

    References 

    1. House JW, Brackman DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2):146-147.
    2. Seiff SR, Carter SR. Facial nerve paralysis. Internat Ophthal Clin. 2002;42(2):103-112.
    3. Borodic G, Bartley M, Slattery W, et al. Botulinum toxin for aberrant facial nerve regeneration: double-blind, placebo-controlled trial using subjective endpoints. Plast Reconstr Surg. 2005;116(1):36-43.
    4. Seiff SR, Sullivan JH, Freeman N, Ahn J. Pretarsal fixation of gold weights in facial nerve palsy. Ophthal Plast Reconstr Surg. 1989;5(2):104-109.
    5. Tower RN. Dailey RA. Gold weight implantation: a better way? Ophthal Plast Reconstr Surg. 2004;20(3):202-206.
    6. Jordan DR, Anderson RL. The lateral tarsal strip revisited. The enhanced tarsal strip. Arch Ophthalmol. 1989;107(4):604-606.
    7. Elner VM, Mauffray RO, Fante RG, et al. Comprehensive midfacial elevation for ocular complications of facial nerve palsy. Arch Facial Plast Surg. 2003;5(5):427-433.
    8. Olver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol. 2000;84(12):1401-1406.
    9. Wiggs EO, Guibor P, Hecht SD, Wolfley DE. Surgical treatment of the denervated or sagging lower lid. Ophthalmology. 1982;89(5):428-432.
    10. Elner VM, Demirci H, Morton AD, Elner SG, Hassan AS. Transcaruncular medial canthal ligament plication for repair of lower eyelid malposition. Arch Ophthalmol. 2007;125(3):374-379.

    Author Disclosure

    Supported in part by an unrestricted grant from Research to Prevent Blindness (New York) and the Lions and Lionesses of Minnesota. Drs. Lee and Harrison state that they have no financial relationship with the manufacturer of any product discussed in this article or with the manufacturer of any competing product.