Facial palsy rehabilitation
The treatment of facial palsy is first directed at preserving the patient’s vision, secondly their ocular comfort, and thirdly correcting facial asymmetry and improving function. Good vision requires a normal tear film with normal position and function of the eyelids. The following medical and surgical treatments are used in the rehabillitation in patients with facial nerve palsy. Many of these surgeries also address the correction of the asymmetry, e.g. brow lifting, upper lid lowering and lower eyelid tightening and elevating as well as mid-face lift.
Preserving patient’s vision and ocular comfort in facial palsy
1. Medical Treatment
- Dry eyes are treated medically using a plethera of lubricating eye drops and gels.
- Lagophthalmos can be treated with simple measures such as padding or taping the eyes shut at night can help prevent corneal damage.
- Severe dry eyes are treated surgically using punctal plugs (temporary) or punctal cauterisation (permanent).
- Brow ptosis is treated by raising the brow
- Upper eyelid closure is assisted dynamically by surgical insertion of a lid load which is often a thin, gold plate weighing 1.2 or 1.4 grams, which is sutured inside the eyelid usually under local anaesthetic. For patients with gold allergies, a platinum chain weight can be used instead.
- The lower eyelid sag and ectropion is corrected by a canthopexy/canthoplasty, such as a lateral tarsal strip or augmented strip. This tightens and elevates the lower lid at the lateral canthus.
- The medial corner of the eyelid can be closed with a medial canthoplasty.
- In patients with severe keratitis and risk of severe loss of vision, the upper eyelid can be lowered by a levator recession in order to protect the cornea.
- Protective ptosis can be induced with an injection of Botulinum Toxin A (e.g. Botox®, Dysport®) into the inner surface of the eyelid.
- Rarely, the eyelids are closed using a tarsorraphy with stitches between the upper and lower lids. This is typically a temporary surgery when there is a severe keratitis.
- Watering eyes in facial palsy can be due to drying, eyelid malposition or poor eyelid pump. Poor tear drainage caused by malfunctioning orbicularis muscle may require a dacryocystorhinostomy (DCR) and Jones’ Tube.
- Some patients with chronic watering eye on eating (crocodile tears) can be treated using an injection of Botulinum Toxin A into the lacrimal gland to prevent watering for an extended period of time.
Correction of Facial Asymmetry in Facial Palsy
- The eyebrows can be equalised by injecting the non-affecting forehead with Botulinum Toxin A to abolish the horizontal frown lines.
- The affected eyebrow ptosis can be elevated with a direct, pretrichial or endoscopic brow lift.
- A lateral tarsal strip (see also above) can be performed, or spacers inserted to raise the lower lids. Common spacers consist of the patient’s own ear cartilage or hard palate. At Clinica London, we also use Surederm® which is donor human collagen.
- A mid-face lift can be performed in more severe cases of facial palsy. This is usually done under general anaesthetic. Incisions are made in specific areas that allow for minimal scarring, ideally hidden with hairs or natural wrinkles. Specific devices to pull the tissues upwards (threads, Endotine®, etc.) can be used, placed beneath the muscles of the face and may be reabsorbable or remain permanently.
- Filler injections with a hyaluronic acid gel (e.g. Restylane®, Perlane®) can also be used in facial palsy rehabilitation. More longer acting fillers include Sculptra® i or autologous fat transfer. The filler is injected into the cheek on the affected side and the nasal labial fold on the unaffected side.