gms | German Medical Science

Facial palsy or seventh nerve paralysis is due to various etiologies. Trauma, ENT or neurosurgical procedures or tumors are generally associated with severe or complete paralysis and have a poor prognosis. On the other hand, idiopathic paralysis or Bell’s palsy is secondary to inflammatory or viral or immunologic factors and is associated with good functional recovery without surgery in 80% of the patients.Surgical treatment is therefore performed as a reconstructive process at least six months after the onset of the paralysis and when evidence of absence of improvement of the paralysis can be demonstrated.

The pathologic condition around the eye is called lagophthalmos.The main symptoms of lagophthalmos are:

• corneal exposure especially if Bell’s phenomenon is of poor quality, or in the presence of corneal sensory loss (fifth nerve palsy).
• ectropion of the lower eyelid (medial and inner part of the eyelid) and the lacrimal punctum.
• epiphora related to several mechanisms: displacement of the inferior punctum away from the lacus lacrimalis, paralysis of the lacrimal pump due to paralysis of Duverney-Horner’s muscle, keratinisation of the punctum.
• downward eyebrow displacement related to frontal muscle paralysis on the pathologic side and upper eyelid retraction on the other side

1.

Nerve repair or nerve anastomoses (most frequently hypoglosso-facial anastomosis) can be considered as a first step in young patients and are performed in general by ENT or plastic surgeons.

2.

Palliative surgery is required when facial nerve can no longer be useful.

2.1.

local measures: the cornea can be protected by regular instillation of eyedrops (methylcellulose or hyaluronate) and by taping both eyelids at night with an adhesive tape (Steristrip^®)

2.2.

tarsorraphies are used in comatose patients as a temporary step. A Frost suture can be used as a downward traction for a few days in order to protect the cornea. Botulinum toxin injection in the levator can also be used as a temporary procedure for the same purpose.

2.3.

Eyelid resection techniques is the most important step for the ophthalmologist. Several techniques have described and can be grouped using the anatomical location:
- outer angle or lateral canthoplasty are performed using the “tarsal strip procedure” of R Anderson, rarely the Montandon technique. It is important to reinsert the tendon on its posterior limb in order to keep the eyelid direction outwards and backwards covering properly the conjunctiva
- inner angle or medial canthoplasty are more difficult as they must keep the eyelid in contact of the conjunctiva and tighten the eyelid and the lacrimal point inwards and backwards. Several techniques using plication of Duverney-Horner muscle (the posterior limb of the medial canthal tendon) are described with a retrocaruncular approach under the microscope with a 300 mm terminal lens. It is better to protect the cornea with a metallic shield during the surgical procedure.
- resection of the posterior lamella of the eyelid (for exemple a pentagonal resection of the tarsus and the conjunctiva) can be associated better as a second step or in combination with the previous ones.

2.4.

Increase weight of the upper eyelid with skin or cartilage, eyelid magnets are rarely used.
Gold implants placed between the upper tarsus and the aponerosis of the levator and the pretarsal orbicularis is a good technique but as a non autologous material it can be extruded and is more costly than the previous techniques

2.5.

Several techniques of the surgical treatment of downward eyebrow displacement are described.

2.6.

Palpebral spring of Morel Facio, Arion sling thread technique are no longer used. Temporalis muscle transfer around the palpebral aperture can be used in Leprosy or as an exceptional procedure.

In conclusion medial canthoplasty alone or in combination in a second step with lateral canthoplasty are our favorite surgical choice and can be performed easily under local anesthesia.