Facial nerve paralysis - Upper eyelid weight

Considerations

• • Indications

    • Incomplete upper eyelid closure

  • Eyelid and eye assessment 

    • Upper eyelid

      • Lagophthalmos

      • Corneal coverage

    • Lower eyelid

      • Ectropion

      • Epiphora 

    • Subjective measures  

      • Eye irritation

      • Cosmesis

    • Objective measures  

      • Conjunctivitis 

      • Keratitis 

      • Visual acuity 

  • Timing

  • 1992: Management of ophthalmic complications of facial nerve palsy

  • Technique

  • 1974: A technique for lid loading in the management of the lagophthalmos of facial palsy

  • 1989: Pretarsal fixation of gold weights in facial nerve palsy

  • 2006: Upper eyelid gold weight implants in patients with facial nerve palsy. Surgical technique

  • Implant materials

    • Gold

    • Platinum

  • Literature

  • 1992: Eyelid reanimation for the treatment of paralytic lagophthalmos: historical perspectives and current applications of the gold weight implant

  • 1998: Efficacy of gold weight implants in facial nerve palsy: quantitative alterations in blinking

  • 2001: Prospective Evaluation of Eyelid Function With Gold Weight Implant and Lower Eyelid Shortening for Facial Paralysis

  • 2014: Lagophthalmos after facial palsy: current therapeutic options

  • 2015: Reanimation of the brow and eye in facial paralysis: Review of the literature and personal algorithmic approach

  • 2016: Management of the Eye in Facial Paralysis

Preparation

• • Determining the weight of the implant

  • Position of the implant 

    • Historically, 3 positions were employed

      • Septal

      • Mid-pretarsal

      • Low-pretarsal  

  • Incision placement 

    • Mark the lid crease 

  • Local anesthesia 

    • Infiltrate the skin with 1% Lidocaine with 1:100,000 Epinephrine 

  • Equipment 

    • Ocuplastics tray 

    • Jeweler's tip bipolar 

    • Protected needle tip Bovie

    • Baron suction #5, #7 

    • Cotton tip applicators  

    • Suture

      • 4-0 Silk 

      • 5-0 Fast gut P-13 

      • 5-0 Vicryl P-3

      • 5-0 Prolene RB-2

    • Medications 

      • BSS

      • Maxitrol ointment 

  • Prep and drape 

Procedure

• • Optional: Place a 4-0 Silk suture through the upper lid margin for inferior traction vs tarsorrhaphy suture with 5-0 Prolene 

  • Incise the upper eyelid skin to expose the orbicularis oculi

  • Dissect through orbicularis oculi to expose the tarsal plate

Sample operative report

Post-op

• • Complications

    • Intra-operative 

      • Scleral injection with local anesthesia 

      • Eye and eyelid injury 

    • Post-operative 

      • Extrusion

      • Infection 

      • Reaction to the implant

      • Entropion

      • Upper eyelid distortion

      • Blepharoptosis

      • Failure to fully improve upper eyelid closure 

  • 1997: Complications of gold weight eyelid implants for treatment of fifth and seventh nerve paralysis

Pearls & Pitfalls

High-Yield

Links

• YouTube (2:48) - Gold Eyelid Weight SutureGroove

• YouTube (5:00) - Gold weight implantation

• YouTube (7:56) - Gold Weight Implant Surgery by Mark May

  • YouTube (8:21) - Gold weight insertion by Ric Ceaser - Excellent surgical instruction

• YouTube (10:44) - Malhotra Platinum Segments: New platinum chain for adjustable upper eyelid loading in facial palsy

• Iowa Protocols - Platinum-Gold eyelid weighting Corneal - eye- protection for Facial Paralysis

• UTMB Grand Rounds - Facial Nerve Paralysis: Management of the Eye

• eMedicine - Static Reconstruction for Facial Nerve Paralysis