• Eyelid Position and Facial Nerve Palsy With Unresolved Weakness

    By Marianne Doran and edited by Deepak P. Edward, MD

    Journal Highlights

    JAMA Facial Plastic Surgery
    Published online June 16, 2016


    Goldberg et al.
    investigated the prev­alence and clinical features of eyelid malpositions in facial nerve palsy (FNP). They found that upper eyelid asymmetry is common in FNP and may be accompanied by other manifes­tations, including ptosis.

    This retrospective cohort study included 52 patients who were seen at University of California, Los Ange­les, plastic surgery and eye institutes. Patients were predominantly female (73%), with a mean age of 44.1 years. Exclusion criteria included prior histo­ry of procedures or medical conditions that could alter eyelid position.

    Primary outcome measures were prevalence of eyelid retraction and ptosis. Eyelid retraction was defined as margin-reflex distant 1 (MRD1) >5.0 mm, while ptosis was defined as MRD1 <2.5 mm. Standard digital photographs of patients seated parallel to the plane of the film in the primary position and with full smile were extracted from a prospectively maintained imaging database. Measurements were performed on these photos, using ImageJ software, which was developed at the National Institutes of Health.

    Overall, eyelid asymmetry (defined as inter-eye difference of >1.0 mm in MRD1 measurements) was present in 14 patients (27%), with the FNP side higher in 12 (23%). Compared with those without asymmetry, patients with eyelid asymmetry were significantly more likely to have contralateral ptosis (42% vs. 2.5%, p < .001). Retraction was found in 8 patients (15%). Ptosis was noted in 4 patients (8%). Synkine­sis was present in 24 patients (46%), but none had concomitant ptosis. Severe FNP (House-Brackmann score >4) was present in 28 patients (54%), and these patients were 20 times more likely to have eyelid asymmetry, often with the FNP side higher.

    With most of the patients in this study, the eyelid position on the FNP side was higher—without demonstrat­ing retraction—and the contralateral side was ptotic. Thus, the researchers concluded that contralateral ptosis surgery may benefit these patients. Furthermore, patients with severe FNP were more likely to have eyelid asym­metry. This suggests that the ability of the eyelid position maintenance system to adapt to weakness of eyelid protrac­tors may be limited by the severity of this weakness.

    The original article can be found here.