Lecture: Facial Palsy: Oculoplastic Management

During this live webinar, we will discuss the diagnosis and treatment of patients with facial paralysis. Surgical rehabilitation of these patients with focus on periocular surgeries will be discussed. Video presentations of surgical techniques including gold weight placement with fat flap and transconjunctival lower eyelid retractor recession will be shown.

Lecturer: Dr. Andrew Harrison, Director, Oculoplastic and Orbital Surgery, University of Minnesota, USA


DR HARRISON: Good morning, everybody. I’m Dr. Andrew Harrison, here in beautiful cold and snowy Minneapolis. And today we’re gonna talk about oculoplastic management of facial palsy. Thanks for coming! So this is a slide of a gentleman with a self-inflicted gunshot wound, but developed facial paralysis due to that injury, and ended up with intermittent complete tarsorrhaphy, and the point of this talk is that we can do better than this. We can do much more aesthetic periorbital rejuvenation of these patients who have facial paralysis. And that’s kind of the background of this talk. So I will talk for a little bit about evaluation, we’ll talk about synkinesis or miswiring, and then management of patients with facial paralysis, and then I’ll spend the bulk of the time talking about surgical rehabilitation and some newer things that I’ve added, that are helped, I think, improve the aesthetic appearance of these patients. So my first polling question — I would just like to know who’s out there, and find out what is your level of training. And if you can fill this in, we’ll get the answers up here in about 30 seconds. So I guess the bottom line is facial paralysis is something we all see. Ophthalmologists, non-ophthalmologists, ER docs. You’ll see it in medical school residency. So most of you are comprehensive ophthalmologists, it looks like. I have medical students, residents, a couple of oculoplastic surgeons, and non-ophthalmologists. So it’s a great smattering of people across the medical and non-medical board. So the facial nerve exits the stylomastoid foramen, and then you see the branches here that serve the facial musculature. We’re gonna focus on the area around the eye. Now, obviously facial paralysis involves the entire face. But I’m mostly gonna focus on treating the area around the eye. Just because that’s my area. That’s our area, I guess I should say. So what do we do when someone comes in with a facial paralysis? First let me back up for a second. With facial paralysis, the most common cause — somebody had put this question up before — that I see is a Bell’s palsy, which is idiopathic. Other causes are patients treated for acoustic neuroma intervention and facial tumors. But it’s important to keep in mind there’s a long differential diagnosis, including Lyme’s, which is the next most common one, sarcoidosis, HIV, and down the line. And it’s important to have these patients initially evaluated by either primary care physicians or otolaryngologists, and the workup may involve an MRI scan. If it’s been there for a while and it’s not changing, that’s a reasonable way to go. But I do send them initially to primary care or ENT, and for the most part, they come back to me when they have problems with their eyes. So now let’s catch up. They come into your office. What are you gonna do? Typical eye exam. Some of the things that I would add to keep in mind are to look very closely at motility. Remember the 6th and 7th cranial nerves are quite close together in the brain stem, so it’s important to make sure that this is not affecting motility, especially the 6th nerve, causing a lateral rectus palsy. And then to look very, very closely at the slit lamp. Looking at the corneal sensation, to make sure that cranial nerve V is not out, before any stain or anesthetic is put in the eye, I guess, is what I was looking for, and before they check the intraocular pressure and create a corneal defect. So I always have the residents pull somebody in to make sure that the corneal exam is checked before any drops are put in the eyes. And then doing a Schirmer’s test to look for tear production issues, and finally a complete eye exam, including a fundus exam. So I’m not gonna focus on that. I’m gonna focus more on the periocular tissues. So we look at the palpebral fissure, scleral show, lagophthalmos, the inability to close the eyes, and the lower eyelid position. On this picture you can see he has almost all the hallmarks of a left facial paralysis. And you can see his lower lid position is low. His brow is low. And when he tries to close his eyes, as you’ll see in some of these next pictures, he can’t. This is another patient with a right facial paralysis. So we’re looking at the upper eyelid now. So lagophthalmos, the inability to close the eye, retraction of the upper lid, I think, occurs mostly with longstanding facial paralysis. And then obviously poor closure. The lacrimal system is also involved, and I think this is sometimes forgotten, because of the punctal ectropion and the true ectropion of the eyelid, scleral show. But the main thing is this lacrimal pump failure. If the eyelid is in a reasonable position, but the patient is having tearing issues, sometimes it’s a very subtle facial paralysis and a failure of the lacrimal pump. So the lower lid actually pulls on the tear sac during closure, and when you lose that pumping action, you’ll lose — you’ll create a situation which increases the tear lake, and potentially causing epiphora and tear spillover. So synkinesis is miswiring of the nerves, and we see this after longstanding Bell’s palsy or from compression of the 7th nerve as well. And what happens is that the signal from one nerve ends up jumping to the other. So that, for example, as you can see in this patient, as she tries to smile, her eye closes. So one branch of the facial nerve ends up innervating another part of the face. You can see that here in this video. This gentleman, as he smiles, his eye closes. And this is probably the most common synkinesis we see. So he’s trying to smile. As he activates that smile, his eye closes up. So this is called the Marin-Amat syndrome, contraction of the orbicularis with lower face movement. You’ve got to separate this from hemifacial spasm, and sometimes it’s hard to do. But hemifacial spasm tends to be more — I use the word “spasmodic”, but more dystonic appearing, where the patient contracts the entire side of the face, rather than — when performing one facial movement, another muscle closes. So the treatment for this is with Botox. Sometimes I do ptosis surgery and Botox. Sometimes I’ll add an orbicularis myectomy to take out some of the orbicularis muscle and tighten the levator at the same time on that side. But Botox tends to work very well. And I use very small doses of any of the botulinum toxins. I guess I should use the more generic name. Any of the botulinum toxins work. With Botox I use 2 injections of 2.5 units, one medially, one laterally, in the orbicularis. Here’s another gentleman with the same issue. And here’s keep calm and get Botox. This is from a friend of mine, a facial plastic surgeon from LA. From his website. You can see you can get great results with Botox. One of the other things you see after longstanding facial paralysis is the so-called “crocodile tears” or the gustatory syndrome, and this is when the facial nerve fibers to the lacrimal gland become associated with the chorda tympani that supplies the tip of the tongue, so that when the patient eats, they have tearing. In my experience, this is very difficult to treat. There are really two options. Trying botulinum toxin to the lacrimal gland can work, and I usually do that transconjunctivally, and put 5 to 10 units in the lacrimal gland. And that works in my hands, I’d say, probably 70% of the time. The other option is to have your ENT colleagues do a sphenopalatine block or ablation to kind of disconnect those two nerves. And when we’re talking about facial paralysis, it’s important to be able to speak the same language as the other doctors who deal with this. So the neurosurgeons and the otolaryngologists use this House-Brackmann scale. I’ve adapted it so it includes the eyelids. House-Brackmann 1 is totally normal. 6 is the nerve is totally out. And the way I think about it is: 3 is eyelid closure with maximal effort, and 4 is incomplete closure, but symmetry. 5 is incomplete closure with asymmetry at rest. So that’s the House-Brackmann scale. And you’ll see that on charts from patients that come from neurosurgery and ENT. It’s just important to be aware of it. So now I just wanted to see: How many patients with facial palsy do you guesstimate you see in your clinic during the year? So we’ll give this another 30 seconds. And then we’ll move on to some of the treatment recommendations, and then my favorite, the surgical rehabilitation of these patients. All right. Let’s see what we’ve got. So mostly you see 0 to 10 patients. Which is pretty typical. Some see more than 25, which is on the high end, I would say. All right, let’s move along. So the acute management of these patients is just taking care of the ocular surface. So the most important thing is corneal lubrication. And I tell patients to use non-preserved tears six times a day at least, initially, and then ointment at night. If the eye is not closing at night, you have to do some sort of taping, and I’ll show my little trick next that I’ve added, and follow up closely to make sure their cornea is not decompensating, and have them come in or call if their eye is red, irritated, or their vision is down. So acutely, you can do a couple things. You can do a tarsorrhaphy to close the eye. You can Botox the levator. And the way I do that is I use a 30-gauge needle, just underneath the rim, the orbital rim, superiorly, and put in 10 units of Botox, and that will drop the lid for about 6 weeks. You just go straight in underneath the orbital rim. And that will get your levator. The other thing — FCI has made these external weights, which the patients can tape on themselves. You’ll need to use a little weight guide that they’ll send you to use in your office to decide how much weight, and then they have four different skin tones. The other thing — before I get to the polling question, I just want to add one other thing. There was a recent article that described using the brand name Glad Press and Seal. And this is something you can use to preserve food. It’s a plastic, and you can cut out a circle of the Glad Press and Seal, and use that to close the eyelid. And that works quite well. It’s a little better than tape, because it’s not as irritating to the skin, and you can use it repeatedly. So that’s one other thing I wanted to add in there. Okay. So now let’s move on to surgical approach. What is your preferred surgical approach to a patient with lagophthalmos? And these are mostly upper eyelid procedures. We’ll talk about both upper and lower eyelid procedures, but I wanted to see what people out there are doing. And my approach has evolved over the last 20 years. And I use a combination of things to help. But let’s see. So most of you do tarsorrhaphy. Good. So hopefully I can teach you something new. I know in parts of the world gold weights or platinum weights aren’t available, so that’s not an option for you, but I do want to talk about my techniques for gold weight. And we’ll talk about — a little bit about some of these other things. I’m gonna mostly focus on upper eyelid and lower eyelid here. But as you know, there’s a variety of surgical procedures that can be done for patients with lagophthalmos and issues related to facial paralysis. So I’m gonna start with gold weight implants, because this has kind of become the mainstay of treatment, in my armamentarium. And it’s been available for over 60 years now. And it’s basically loading the lid with weight to let gravity close the eyelid. It’s really become the standard of care here, I would say, in the last 15, 20 years. Although things are changing. We’ll talk about that as well. So this is from Stu Seiff’s article in 1989, where he talked about pretarsal fixation of the gold weights, and we’ve really moved far from here, but this is still an excellent technique. So the gold weight is secured to the tarsus. I know these are kind of a little bit fuzzy. But I’ll show you a video of my technique here, in a few seconds. The problem with pretarsal fixation of the weight is it’s kind of rife with complications, including infections, extrusions, migrations, but the biggest thing, I would say, especially in patients that require a large weight, is this big lump in the pretarsal area, and then patients can develop chronic redness, either from the weight sitting on the eye or from an allergy to gold, and that’s why they came out with platinum weights more recently. So this is another picture from an article in Plastic Surgery, showing an extrusion. Here’s one of my patients that presented with redness, and an extruding and infected weight that we saw. The pretarsal fullness is a problem, especially, like I said, in the larger weights. And here’s a young woman with that pretarsal fullness on the right side. So one of the things that came after the extrusion problem was — maybe we should wrap the weights in Dacron. Fascia lata. There’s a variety of things out there. All of them led to their own problems. They’re second surgical sites, et cetera. So Robert Tower and Roger Dailey came up with this. Implanting a large weight, high up on the tarsus. And they described this about 15 years ago now. And this was from their initial paper. They had a special ordered 2.2 gram weight that they sutured to the levator. The septum was then closed over it, and they saw improved exposure, and only had two complications in their series. So I modified my technique, and this was published — you can see the journal trial up there from 2015 — combining the recession of the levator, so I recessed the levator, and I placed the weight between the levator and the tarsus, and I typically use a 1.4 to 1.8-gram weight, and I’ll show you that here in a video. The weight is chosen preoperatively. So I have the patients in the office seated, and I have this weight selection kit, and I tape them with double stick tape to create a small amount of ptosis, and I tape it pretarsally, but since I’m placing it higher and deeper, I add 0.2 grams to that weight I’ve selected. So I would say this is probably a bit too heavy. I would probably back off of that weight. But you can see she’s got a Hering’s retraction on the right side as well. So this is the technique. This is with high temperature cautery. You can see I’m opening the tarsus on the left, which is the asterisk, and the levator is in my forceps. And then I sew the weight between the tarsus and the levator aponeurosis on the right. All right, here’s a video showing it, this technique. And I’ll show you one other thing that I’ve added recently. So a skin crease incision with a 15 blade. And then I’m gonna use a monopolar cautery here to dissect down to the tarsal plate, which is inferior, or on the right side of your screen, and I’m opening the septum. I like to mark the center, where I want to center the weight. Sometimes over the pupil. Sometimes it’s a little bit more nasal, to get better closure. But I want to find the area that gets the best closure. So now I’m suturing the inferior holes of the weight to the tarsal plate, and I use a 5-0 Mersilene suture for this. I think a permanent suture is necessary in this. I’ve tried using vicryl and some absorbables, but the weight tends to slip inferiorly, due to gravity, as it is, so I like to have a permanent suture in there. Although one of my teachers said the only permanent suture is a scar. And that’s probably true. But until that scar forms, I like to have a permanent suture holding it in place. And you’ll see here I’m gonna suture the top hole to the levator aponeurosis. So that’s the levator being sutured to the top of the weight. This is a platinum weight. Platinum weights are a little thinner, since platinum is a more dense metal. And it just kind of depends what hospital I’m in. The other thing that I’ve added — and this is showing this here — is I suture the central fat, the postaponeurotic fat pad — I’m sorry, the preaponeurotic fat pad, to cover the weight. So using the patient’s own fat as a cover for the weight. And this is a technique I picked up from my friend Guy Massry in Los Angeles. And this works really well to help camouflage the weight and help with extrusion. You can see the fat flap sewn over it, and I close the orbicularis in this case — I’m using a 6-0 vicryl — and I used the 6-0 vicryl to close the fat flap as well, and this is 6-0 vicryl suture to close the orbicularis as well. I don’t always close orbicularis in these cases, but here I do, again, to prevent extrusion and exposure of the weight, and this is a running 6-0 plain gut suture, but you can use the suture of your choice here, and just tie it off at the end. So that’s my current technique for gold weight implant. These are the results from our study we looked at of patients we had done over the last 5 years or so. We found the MRD1 did drop a little bit postoperative. So it went down about a millimeter or so. But lagophthalmos went down by about 3.5 millimeters, and the corneal score improved significantly. And you can see when we did other procedures, such as lower lid tightening, the MRD still went down. Not quite as much. And the lagophthalmos improved even more. Just to show a couple patients, here’s a patient before and after. This is with a gold weight in the right upper lid, and a tarsal strip in the lower lid. Here’s another patient with a gold weight, pre- and postop. One more. Left upper lid. You can still see the sutures. But she really improved her lagophthalmos. And another. This one I wanted to show. Because this is — we can do better. This kind of illustrates that point the best. This is a lady that came in with a tarsorrhaphy she had had for ten years. We open the tarsorrhaphy, did a lateral canthoplasty and put a gold weight. You can see it’s up high in the eyelid, and she has excellent closure and markedly improved cosmesis. So now let’s focus on the lower lid. Paralytic ectropion is this unopposed force of gravity on the lower lid, and stretches the lower lid and the lateral canthus out. Leads to poor tear distribution, and as I was talking about earlier, the failure of the lacrimal pump. There are several things we can do for paralytic ectropion. Horizontal tightening has become kind of the mainstay of that procedure. The mainstay procedure for paralytic ectropion. We can also do spacer grafts, midfacelifts, and put a fascia lata sling in. The other thing I want to show is: Recessing the lower lid retractors can let the lid come up a couple millimeters as well. So I just want to show my technique for tarsal strip. I call it the hi-temp tarsal strip. I use the high temperature loop wire cautery. Super hot tip. It gets to 2300 degrees Fahrenheit. The key is to do it with no oxygen or to have the anesthesia folks turn down the oxygen, and the key is to use kind of paintbrush strokes. You don’t want to touch it and hold it there. Just use little tiny strokes with it. And if it starts to cool down, you can get another one. Some of the newer ones have batteries that are giving out earlier than they should. So here’s the technique. Starts in the upper left hand panel there. Lateral canthal incision with a 15 blade, then I use the cautery to do a canthotomy, and then pull the lid inferiorly and distract it, and as you do that, make the incision just at the inferior tarsal border, and you’ll see the lid release at the lower lid crease and the septum. And then use the high temperature cautery to remove the epithelium. You don’t want to implant epithelium into the orbit. So I use that, and I separate the anterior and posterior lamella. That’s in the upper corner panel. And then moving to the right, excise a little excess skin, and orbicularis muscle. And then use two cotton tip applicators to spread over the orbital rim, to get the periosteum exposed, and then using a double armed 5-0 suture of your choice, I’m currently using PDS — I was a vicryl user for years — it doesn’t really matter. My partner uses 5-0 prolene here. You can use anything. Just — you need to support and secure the lateral canthal tendon, the lateral tarsus, to the lateral orbital rim periosteum. And then I put in a canthal reforming stitch to try to create a nice lateral canthal angle. And you can see that on the upper left, placing the stitch through the grey line, and then back through the grey line and out through the wound, and tie that to get a nice sharp lateral canthal angle, and then close the skin again with the suture of your choice. Here’s a patient with a facial paralysis before and after lateral tarsal strip. So one of the newer things that’s come out is this recessing the lower eyelid retractors to allow the lower eyelid to come up, to help with closure, and I have used this in patients with facial paralysis as well, and the nice thing is: You stay away from the orbicularis muscle. And that’s why this minimally invasive orbicular sparing or MIOS procedure, developed by Guy Massry in LA. And this is from the paper. You can see the lower lid has been incised at the inferior tarsal border, transconjunctivally, and the lower lid retractors are dissected from the underlying conjunctiva. You can do this sharply with scissors, or as I’ll show in the video here, I’ve done it with the cautery as well. Here’s that video. This is just a quick one. So incisions made at the inferior tarsal border, Jaeger lid plates used to protect the eye, through the conjunctiva and lower lid retractors, I use a coated Desmarres retractor to protect the lid, and then make an incision to release this. And then you can put this on traction with a 4-0 silk suture and tag it superiorly, which I’m doing here, so that suture goes through the conjunctiva and lower lid retractors, and is tagged superiorly to the drape, or just used to provide countertraction. And then the lower lid retractors are dissected from the underlying conjunctiva, and like I said, you can do this either sharply, or with a cautery. And then just checking lid position and removing the stay suture. The other thing you can add — rather than doing a formal tarsal strip, and this is another patient. So we’ve done the gold weight. We’re gonna do a gold weight as well. But this is an approach to the lower lid lateral canthus through the upper eyelid. So I’m dissecting the suborbicularis plane, over the orbital rim, and you can see you can release the lateral canthal tendon here with your scissors. You can strum across it the same way you would to release the inferiorly canthal tendon, and then I’m taking a 5-0 PDS suture, coming up over the canthus, engaging the canthus, so this is for patients with minimal lower lid laxity, but a way to pull up that canthus. You can see as I pull on it, it tightens the lower lid. Then I’m gonna suture that to the lateral orbital rim periosteum here. This is all done through the upper eyelid incision. And spares the lateral canthal incision in these patients that just have mild lower lid laxity. With their facial paralysis. But it just tightens the lid and helps improve their closure. So we call that the closed canthoplasty. So this is another patient that we did a lower lid recession. This is using the high temperature cautery recession. The lower lid retractors, away from the conjunctiva here. And in this patient, I did do a formal lateral tarsal strip canthoplasty, and there’s suturing the lateral tarsus. Here she is afterwards. We put her up under a Frost suture for five days, and you can see she has mild upper and lower lid retraction. But fairly good tone, and here is right after removal of the frost suture, and here afterwards, you can see the right lower lid in a much improved position. This is eight months out. So it does have some staying power as well. A couple more patients that are done with this procedure. So releasing the lower lid retractors, and an upper lid approach to pulling up the lateral canthus. These are from Dr. Massry’s paper. So if the lower lid is too far down that a lower lid recession is not gonna work, which is maybe 1 to 2 millimeters at most, you need to do something else. The something else can be a cheek lift with a graft. So a hard palate graft is kind of the gold standard for an internal implant, to help support the eyelid. The other thing you can use is these acellular dermal matrix. This is the one called Alloderm. I like thick Alloderm for the spacer grafts in these patients. It’s freeze-dried acellular matrix. It’s had all the cellular components removed. So it’s a low risk of infection. These come out of a freeze-dried package and we reconstitute them on the operating room back table. So this is what it looks like. The conjunctiva is incised in the same place in the lateral canthus. You can see the graft on the top left has been sutured into the lower tarsus, and to the lower lid retractors, inferiorly. And that will pull up the eyelid. Here’s a patient with a spacer graft in the right lower lid. And an upper lid recession. So the other thing you can do is tuck up the malar fat pad, to help support the lower eyelid in these patients that have lower lid retraction. Here’s lateral canthal incision, lateral canthotomy, cantholysis, incision down to the orbital rim, and picking up the fat pad and securing it to the periosteum to help elevate that lateral cheek tissue, and then Alloderm graft being sewn into the conjunctiva and the lower lid retractors inferiorly, and the inferior tarsus superiorly. And one little trick to sewing in these grafts — it gets a little tricky — is to do the inferior edge first with the graft flipped against the eyeball, and then flip that graft up into the upper portion, and suturing that second. Like so. There it is, sewn in place, lateral canthus is secured, and the skin is closed. And it’s put on a lateral frost suture in this case. And here’s the patient — this is the patient that had that big weight in her upper eyelid, but still had lagophthalmos. This is after a cheek lift and a hard palate graft to the internal lower eyelid, and a canthoplasty. So now we’ll move on to the brow, and I’m not gonna spend a lot of time here. But I just want to say there’s a lot of ways to lift the brow. And in facial paralysis, I like the midforehead lift for several reasons, and I don’t only use midforehead lifts — for more aesthetic patients, I might use a more temporal or endoscopic-type lift. Direct brow lift works quite well. But the midforehead lift is kind of nice, and you can do it unilaterally. The reason it’s nice is: Patients with a longstanding facial paralysis who have wrinkles on the side of the forehead that moves and no wrinkles on the other side, so you can take advantage of that and create a wrinkle in an otherwise flat forehead. So I think endobrow, you can get enough lift for mild brow ptosis. The direct lift is a nice procedure, well known to ophthalmologists, where you just excise skin and subcutaneous tissue. In a direct brow lift, though, in patients with facial paralysis, I would say the thing that I add is deep fixation suture with a permanent suture. So instead of just closing the subcutaneous tissue and the skin, I will put some deep fixation sutures in. The internal browpexy, external browpexy, I feel like you don’t get enough lift in these patients, and I do like the midforehead lift in these patients. Especially older men. It tends to work really nicely. So this is the way we do it. I usually mark a matched rhytid that you can determine with them in the seated preoperative area. Elevate the tissue and mark the excess tissue to be removed in the operating room. Infiltrate them with local anesthetic, and then I use a 15 blade and excise the skin and subcutaneous tissues down to the frontalis muscle with the cautery, and then I close the deep layer with 5-0 vicryl, skin with 6-0 prolene sutures, removed about 7 to 10 days later, and then antibiotic ointment, obviously. This is just showing — this is obviously not from my slides. From a book. But just a nice way of doing this. You can do asymmetric, so it’s not matched up. But you can get a nice lift, and creating that wrinkle in a patient with a flat forehead can work quite nicely. Complications of brow lifting from directly going through the tissues are numbness, obviously, getting infection, more commonly undercorrection than overcorrection in these cases, and wound dehiscence if you don’t get a nice closure. So in summary, facial palsy is common. Right? We’ve all seen it, obviously, by our polling there. Your first job as an ophthalmologist is to protect the eye. And second is to consider rehabilitative surgery when stable. And I would say stable is six to twelve months of stability. So if you can keep them protected until that point, and then go ahead with some of these procedures, I think you’ll have nice results in your patients. Thank you. So this is my contact information. I’m happy to send videos or discuss cases directly with you. At this email address, or through Orbis. So I’m gonna move to the Q and A section. So if anybody has questions, I would be happy to answer those. I’m just gonna read through them as we go. So you can just type them in. And I’m just gonna answer these live. For another 10, 15 minutes or so, and then I have to go to the operating room downstairs here. The first question is: After how long can you plan for permanent tarsorrhaphy in a patient with facial nerve palsy? And I think six months is reasonable. You can do a tarsorrhaphy right away. Especially in patients with the complete lower lid ectropion. Really having problems with closure. I think doing a tarsorrhaphy is totally fine. I would probably wait six months before putting in something permanent. Let’s see. The next question… How do you deal with gold allergy? I use platinum weights in those patients. And that’s gonna be a good way around it. I do want to add… If you don’t have gold weights or platinum weights available to you, I think doing an upper eyelid recession procedure is a reasonable way to go. Either an internal Mullerectomy-type procedure, external levator recession, works really well. The other thing I want to put out there — and this is something that’s new and just coming out in the literature — is orbital decompression for patients with facial paralysis. Patients who have facial paralysis have what looks like apparent proptosis. Even though we know it’s upper eyelid, lower eyelid retraction. But doing a decompression will help the eye move back, and help with the blank dynamics. And that’s something that’s new, and we just started. The next question: After doing an eyelid recession for lower eyelid, then do we need to do on both eyes cosmetically? Usually not. Usually in a facial paralysis patient, it’s asymmetric enough that just doing one side is enough. Sometimes if they do have a little laxity on the other side I’ll do a canthoplasty without the eyelid recession. Next question: Can we use anything to replace gold or platinum weight? In those patients, upper eyelid recession works really well. So an internal Mullerectomy-type procedure or a levator recession procedure works really well on those cases. So if anybody has any other questions, you can type them in there. Otherwise… We’ll end this session. And again, if anybody has any questions, you can reach me through my email. Which is just my first initial, A, and then my last name, Harrison. H-A-R-R-I-S-O-N, at UM as in Mary, N as in Nancy, dot edu. So I’m gonna answer a few questions that had been posted from registration. So which orbicularis do you remove? Preseptal or pretarsal? I’m assuming this question is regarding an orbicularis myectomy, and my answer is both. So when I’m doing an orbicularis myectomy, either for hemifacial spasm, synkinesis, or blepharospasm, I remove the preseptal, pretarsal, and the bit of the orbital orbicularis as well. On these patients. Okay. I’m gonna move to some of the other questions. That you guys have asked. How would you go about ptosis correction when the Bell’s phenomenon is poor? Is it left untouched or is it undercorrected? So in patients with poor Bell’s phenomenon, I typically choose an internal Mullerectomy or a Putterman-type procedure to leave the orbicularis untouched, so I do an internal Mullerectomy procedure in those patients. I usually don’t undercorrect. I usually shoot for even in those patients. And then the next question was: Management of inadequate closure of the lid following ptosis surgery. So that’s an excellent question, and it goes to that first question. So in patients who don’t have good closure after ptosis surgery, the question is: How is the cornea handling it? If there’s corneal problems, and I’ve done a levator-type procedure, I will go and release the levator stitch that’s holding the eyelid at too high a point. You can try massage early, so having the patient just massage along their eyelid. Ten times a day or so. And see if you can get it to drop. But for the most part, in those patients that are having corneal issues, I’ll go and repair or recess the levator. Well, the next one is a good one. The goal of non-surgical treatment with fillers. I did mean to bring this up when I was talking about weights. You can use the hyaluronic acid gel fillers as a kind of filler weight, if you will, in these patients with lagophthalmos from facial paralysis or for other reasons. And basically you just fill the upper eyelid in the pretarsal space, until the lid comes to a normal height and closure. And that’s a really nice non-surgical way to get the upper eyelid loaded, especially in the kind of early phase, when you don’t want to put a weight in, if the patient may have some facial nerve recovery. And it’s reversible with hyaluronidase. That’s a great question. Thanks for putting that in there. Treatment of exposure keratitis. I like to use, as I said in my slides, artificial tears, non-preserved artificial tears, at least six times a day, and lubricating ointment at night, and then at night using something to tape the eye closed, if it’s not closed completely. The next question is: What is the most common cause of facial palsy? Most common is probably an idiopathic Bell’s palsy, although like I said, in my hospital, I do see a lot of neurosurgical and ENT. Postsurgical patients that develop facial paralysis as well. Patients with idiopathic Bell’s palsy do need a workup, because there are treatable causes. So you need to make sure they get a complete workup with their primary care doctor or an ENT doctor, to make sure they don’t have an underlying Lyme, sarcoid, something like that, causing their facial paralysis. What to do about dacryocystitis and lagophthalmos? Well, the dacryocystitis first needs to be treated with antibiotics, and if it’s causing pain, they have a large mucous or infected abscess, that needs to be drained, and the lagophthalmos needs to be treated the way we talked about. With lower lid or upper lid procedures. And then they probably need a DCR, down the road. What’s the best surgical option for patients with lagophthalmos and entropion in the same eye? So in those patients, usually tightening the lower lid and affixing the lower lid retractors will help. So getting the lower lid in a better position usually takes care of both the lagophthalmos and the entropion. I do a lateral tarsal strip and sutures as kind of my go-to for entropion, but you can also do a direct connection or direct suturing of the lower lid retractors to the inferior tarsus. When could one operate in a case of traumatic levator palpebrae superioris disinsertion? So if a trauma goes full thickness through the eyelid involving the levator, I try to fix that at the initial procedure when I’m suturing the eyelid. I look for the levator and try to reattach it. Otherwise, I would give it six months to heal, before I go ahead and correct it. I’m gonna move on. There are a couple more questions that have come in. Can you have exposure in patient with gold weight implant due to lid getting pulled up while sleeping at night? Yes, definitely. I definitely see that sometimes, and in those patients, I have them do the same thing. Ointment and taping, or ointment and just gently closing the eye at bedtime will help the eyelid stay closed. Putting a weight above the tarsus, is there a chance of them migrating towards the conjunctiva? That’s an excellent question, and something luckily I have not ever seen. So I’ve been doing this procedure probably for 15 years, where I put the weight on the Muller’s muscle and conjunctiva. I have not seen any erosion through the conjunctiva causing any problems, but that is for sure a risk of this procedure. And again, why I like to use permanent sutures to hold it in place. If there’s any other questions in there, you can type them in. Otherwise… All right, thanks, everybody, for joining. I hope you enjoyed this session. And we’ll hopefully talk to you later. Bye-bye. Thanks.

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February 7, 2019

Last Updated: October 31, 2022

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