Treatment of Symptomatic Facial Nerve Paralysis with Lower Eyelid Fascia Lata Suspension

Sir:FigureThe facial nerve plays an integral role in eye protection. Facial nerve function may be compromised when a patient sustains an idiopathic Bell palsy, trauma, retroauricular tumor removal, congenital palsy, or cutaneous skin cancer excision. Patients who present with facial nerve palsy often present with symptoms of corneal exposure, including pain, eye redness, and tearing. Classically, the ophthalmic management of facial nerve palsy has involved loading the upper eyelid with preselected weights to promote lid closure.1 Complications associated with these weights have included overcorrection and undercorrection, extrusion, infection, and allergy. Other methods of promoting eye protection have included wire springs, Silastic prostheses, temporalis transpositions, canthoplasties, tarsorrhaphies, and lower eyelid cartilage implantation.2–5 We studied how patients with symptomatic facial nerve palsy and paralytic ectropion fared after undergoing fascia lata suspension of the lower eyelid as a primary procedure when lubrication alone had failed. Twenty-three consecutive patients with nonresolving facial nerve palsy were identified. One patient was excluded from the study with a complex history of extensive orbitofacial trauma. Facial nerve function was evaluated by assessing orbicularis tone, which was graded subjectively (from 0 to 4+). Our surgical approach to fascia lata suspension was similar to that described by McCord and Codner.2 The most common cause of the facial palsy was a nonresolving Bell palsy (seven of 22). Other causes included trauma, congenital seventh nerve palsy, retroauricular tumor removal, post–parotid tumor removal, stroke, brain tumor, and post–skin cancer excision (Table 1). All of the patients in our series presented with tearing complaints, eye irritation, redness, or pain. Physical findings in all patients included diminished orbicularis tone, ectropion, lagophthalmos, and exposure keratitis.Table 1: Patients with Symptomatic Facial Nerve Palsy Who Underwent Lower Eyelid Fascia Lata SuspensionAfter fascia lata suspension, symptoms including tearing, irritation, pain, and discomfort improved in all patients. The average preoperative and postoperative lagophthalmos was 6.5 and 2.9 mm, respectively. Four patients had simultaneous gold weight placement, and one patient had one placed after the primary procedure (fascia lata suspension) because of significant upper eyelid retraction. Patients were seen at 1 week and at 1 month, and were followed for an average of 163 days. There were no extrusions or reactions to the banked fascia lata (Tutoplast). Addressing the lower eyelid alone with fascia lata suspension may ameliorate symptoms without operating on the upper eyelid. Patients who had a good Bell phenomenon, burying the cornea below the upper eyelid on eyelid closure, did not need pretarsal weight placement to resolve their symptoms (Fig. 1). Those patients who had a poor Bell phenomenon or significant upper eyelid retraction and were unable to bury their corneas were more likely to have a successful outcome with fascia lata suspension of the lower eyelid when pretarsal weights were placed (Fig. 2). Frequently, other procedures were performed to obtain an adequate functional and individualized aesthetic outcome, usually addressing the punctal malposition and the gravitational collapse of the hemiface. We did not find that treating the clinical sign of lagophthalmos was necessary. In most patients, postoperative lagophthalmos alone, when present, did not cause any symptoms. As such, we did not elect to place upper lid weights in these patients. Primary lower eyelid fascia lata suspension addresses the facial nerve palsy patient's symptoms and provides an excellent aesthetic result.Fig. 1: Patient with nonresolving left Bell palsy causing eye irritation as a result of a paralytic ectropion and lagophthalmos is shown before (above) and after (below) left lower eyelid fascia lata suspension, fat transfer, and AlloDerm placement for paralytic ectropion and overzealous blepharoplasty, respectively. Postoperatively, there is 1.5 mm of lagophthalmos and the patient is comfortable.Fig. 2: (Above) Preoperative appearance of a patient with right facial palsy after parotid tumor removal. (Below) Postoperative views show the patient after right internal eyebrow elevation, bilateral upper blepharoplasty, right upper eyelid gold weight implantation, and right lower eyelid fascia lata suspension for epiphora, eye irritation, and lagophthalmos with a poor Bell phenomenon that does not bury cornea.Srinivas S. Iyengar, M.D. Eyesthetica Michael A. Burnstine, M.D. Eyesthetica and, Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, Calif. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No external funding was received. PATIENT CONSENT Patients provided written consent for the use of their images.