Facial nerve palsy: providing eye comfort and cosmesis

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Moebius Syndrome: An Updated Review of Literature

Moebius Syndrome, is a rare, non-progressive congenital neuropathological syndrome characterized primarily by the underdevelopment of the facial (CN VII) and abducens nerve (CN VI). Other features of Moebius Syndrome include facial nerve paresis, ophthalmoplegias, orthodontic deficiencies (including crowded dentition, swollen and hyperplastic gingiva, dental calculus, etc.), musculoskeletal abnormalities, and impaired mental function. Due to the rarity of the disorder, very few case studies have been reported in the literature. This article summarizes the significant features of the disease according to commonalities in reported cases, along with several newly recognized features cited in recent literature. We have explored the different diagnostic criteria and the newly recognized imaging modalities that may be used. Understandably, the condition detrimentally affects a patient's quality of life; thus, treatment measures have also been outlined. This study aims to provide updated literature on Moebius Syndrome MBS and improve understanding of the condition.

Putting the Pieces Back Together: Optimizing Function and Appearance after Orbital Surgery

Objectives  To describe medical and surgical options and techniques for functional and aesthetic abnormalities after orbital surgery and multidisciplinary approaches that include the orbit. Design  A review of current management options in outpatient clinics and ambulatory surgery centers with selected illustrative cases. The rationale for choosing specific medical and surgical interventions will be discussed with a focus on eyelid malposition and double vision. Setting  Outpatient clinics and ambulatory surgery centers. Participants  Patients with eyelid, orbital, eye muscle, and scalp contour abnormalities as a result of medical and surgical interventions for brain and/or orbital tumors. Main Outcome Measures  Descriptive outcomes. Results  A variety of medical and surgical options are available to optimize eyelid, orbit, extraocular muscle, and scalp structure and function.

Treatment for ophthalmic paralysis: functional and aesthetic optimization

Facial nerve palsy has an effect on a person's well-being functionally and psychologically. Therefore, comprehensive patient management is essential. One of the most common uncomfortable and potentially debilitating features is associated with the incapacity for eye closure. Restoration of eye closure is a key consideration during the surgical management of facial palsy. In this article, we introduce simple surgical methods-which are relatively easy to learn and involve the upper and lower eyelids-for achieving eye closure. Correcting upper eyelid function involves facilitating the component of eye closure that is in the same direction as gravity and is, therefore, less complicated and favorable outcomes than correction of lower lid. Aesthetic aspects should be considered to correct the asymmetry caused by facial palsy. Lower eyelid function involves a force that opposes gravity for eye closure, which makes correction of lower eyelid ectropion more challenging than surgery for the upper eyelid, particularly in terms of effecting a sustained correction. Initially, proper ophthalmic evaluation is required, including identifying the chronicity and severity of ectropion. Also, it is important to determine whether or not lateral canthoplasty is necessary. The lateral tarsal strip procedure is commonly used for lower lid correction. However, effective lower lid correction can be achieved with better cosmesis when extensive supporting techniques are applied, including those involving cheek tissue.

Management of Long-Standing Flaccid Facial Palsy: Periocular Considerations

Ineffective eyelid closure can pose a serious risk of injury to the ocular surface and eye. In cases of eyelid paresis, systematic examination of the eye and ocular adnexa will direct appropriate interventions. Specifically, 4 distinct periorbital regions should be independently assessed: eyebrow, upper eyelid, ocular surface, and lower eyelid. Corneal exposure can lead to dehydration, thinning, scarring, infection, perforation, and blindness. Long-term sequelae following facial nerve palsy may also include epiphora, gustatory lacrimation, and synkinesis.

[Ophthalmic manifestations of facial nerve palsy]

Facial nerve palsy is a common pathology that develops due to various diseases, traumas and medical interventions. The most common peripheral type of facial paralysis leads to acute unilateral involvement of facial muscles along with the development of paralytic lagophthalmos. The absence of adequate and timely medical treatment in patients with paralytic lagophthalmos can lead to severe corneal complications such as cornea perforation causing loss of eye and consequently restricted professional ability, work capacity and significant decrease of patient's life quality. Patients with paralytic lagophthalmos require timely, complex, planned treatment involving various correction methods aimed at protection of the cornea, as well as anatomical and functional recovery of the eyelids. Chemodenervation of the upper eyelid muscles is a pathogenetically substantiated method that can help restore the protective function of the upper eyelid and prevent corneal complications; it can be recommended for early stages of the disease.

[Staged complex treatment of paralytic lagophthalmos (case report)]

Paralytic lagophthalmos, resulting from facial nerve palsy, is a difficult medical and social issue that requires cooperation of different specialists. Complications that arise in paralytic lagophthalmos may cause significant vision loss and even eye loss. Various techniques of paralytic lagophthalmos correction are used to protect the cornea and restore eyelid anatomy and functions. These comprise palliative (conservative), surgical, and alternative treatments (such as botulinum toxin type A therapy). Surgical treatment of paralytic lagophthalmos patients often has to be staged and complex. This article presents a clinical case of a female patient with paralytic lagophthalmos complicated by corneal perforation. Her staged complex treatment included lower eyelid surgery, chemodenervation of the upper eyelid levator and optical reconstructive surgery. The following positive results were achieved: the protective function of the eyelids was restored, residual visual functions - preserved, the risk of eye loss - eliminated, and the asymmetry between the two halves of the face - corrected.

Association of Eyelid Position and Facial Nerve Palsy With Unresolved Weakness

IMPORTANCE

Understanding the prevalence and clinical features of eyelid malpositions in facial nerve palsy (FNP) may inform proper management of patients with FNP and supplement our knowledge of eyelid physiology.

OBJECTIVE

To describe eyelid malposition in FNP.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, patients with FNP seen at the Center for Advanced Facial Plastic Surgery and Jules Stein Eye Institute between January 1, 1999, and June 1, 2014, were reviewed for study inclusion. Data collection was performed between June 1, 2014, to August 1, 2014, and data analysis was performed between June 15, 2014, to September 1, 2015. The distances from the center of the pupil to the upper eyelid margin (marginal reflex distance 1 [MRD1]) and to the lower eyelid margin (marginal reflex distance 2 [MRD2]) were measured on photographs of patients in the primary position and with full smile. Eyelid asymmetry, retraction, ptosis, synkinesis, and severity and duration of FNP were assessed. Eligible participants were adults with FNP at a private tertiary care clinic with primary position photographs. Exclusion criteria included prior history of procedures or medical conditions that could alter eyelid position.

RESULTS

The 52 included patients were predominantly female (38 [73%]), with a mean (SD) age of 44.1 (13.8) years. Of this group, 34 patients (65%) were white, 8 (15%) were Asian, 8 (15%) were Hispanic, and 2 (4%) were African American. Retraction (MRD1, >5.0 mm) was present in 8 patients (15%), 3 of whom had eyelid asymmetry (MRD1, >1.0 mm). Overall, total asymmetry of greater than 1.0 mm 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) but did not have a significantly shorter duration of FNP (12.3 months vs 13.8 months, P = .82). Ptosis was noted in 4 patients and was also unrelated to duration of FNP (9.6 months in patients with ptosis vs 13.6 months in those without, P = .60). Synkinesis was found 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 asymmetry greater than 1.0 mm, often with the FNP side higher.

CONCLUSIONS AND RELEVANCE

Upper eyelid asymmetry is common in FNP. In most of the patients in this study, the FNP side was higher without demonstrating retraction, and the contralateral side was ptotic. Thus, contralateral ptosis surgery may benefit these patients. Furthermore, patients with severe facial weakness were more likely to have eyelid asymmetry, suggesting 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.

LEVEL OF EVIDENCE

3.

Lagophthalmos after facial palsy: current therapeutic options

As the facial nerve carries sensory, motor and parasympathetic fibres involved in facial muscle innervation, facial palsy results in functional and cosmetic impairment. It can result from a wide variety of causes like infectious processes, trauma, neoplasms, autoimmune diseases, and most commonly Bell's palsy, but it can also be of iatrogenic origin. The main ophthalmic sequel is lagophthalmos. The increased surface exposure increases the risk of keratitis, corneal ulceration, and potentially loss of vision. Treatment options are wide; some are temporary, some permanent. In addition to gold standard and traditional therapies and procedures, new options are being proposed aiming to improve not only lagophthalmos but also the quality of life of these patients.