Facial Palsy (paralysis of the facial nerve)

Facial palsy is paralysis of part of the face caused by damage to the facial nerve (also called the 7th cranial nerve).

Facial palsy is usually acquired – it can be associated with a viral illness but often no cause is found. This is termed a Bell’s palsy. Less commonly it can be a congenital problem (ie. children are born with a paralysis of the side of the face) or a tumour can compress the facial nerve along its path. Injury or a stroke can also cause paralysis of the facial nerve.

The facial nerve controls the muscles of facial expression.

Paralysis of the facial nerve can result in numerous problems relating to the eye and structures around the eye in particular:

  • A sagging lower eyelid (a paralytic ectropion)
  • Incomplete eyelid closure (lagophthalmos)
  • Dry eye & corneal ulcer (due to exposure of the surface of the eye)
  • Watery eye (due to a failure of the eyelids to pump tears out of the eye and into the tear drainage system)
  • Upper eyelid retraction – the loss of orbicularis muscle function not only makes eye closure difficult but also causes the upper lid to rest at a higher level.
  • A droopy eyebrow (brow ptosis)
  • Aberrant reinnervation – the facial nerve attempts to regrow after damage but abnormal connections result in undesirable  twitches of eyelid muscles and closure of the eyelid when moving the mouth.
  • Crocodile tears – embarrassing watering from the eye occurs when chewing food. This is an example of a phenomenon called aberrant reinnervation of the facial nerve. The damaged facial nerve attempts to regrow  but instead of reaching the facial muscles it connects abnormally to the tear-producing gland (the lacrimal gland)
  • Neurotrophic cornea – some patients lose sensation to the eye. This compromises the health of the cornea and makes it impossible for them to feel irritation from drying of the eye or foreign bodies entering the eye. The eye is at risk of corneal ulceration and infection and visual loss. 

Other effects of a facial palsy include: 

  • Sagging of one side of the face
  • Difficulty moving the mouth on the affected side – eating, drinking and speech can  be affected

Treatments for Facial Palsy

Non-surgical Eye Treatments for  Facial Palsy

  • Lubricant Eye drops- ideally these should be preservative-free so they can be safely instilled as frequently as required e.g/ Hyabak (available online from Mr Ataullah’s clinic Face & Eye’s online shop at: www.faceandeyeshop.co.uk)
  • Lubricant Ointment e.g. Lacri-Lube or VitA-POS – this is very useful as a long-acting lubricant at night when the partly open eyelids can result in marked drying of the eye
  • Taping of the eyelids at bedtime is beneficial but the patient has to be careful to completely close the eyelids with the tape to prevent the eye rubbing on the tape
  • External upper eyelid weights – these small skin-coloured weights stick onto the upper eyelid skin and help with blinking and eyelid closure
  • Botulinum toxin injections (e.g. Botox, Dysport) Some patients need to have their upper eyelids lowered with Botox to paralyse the muscle which opens the eye — this allows the eyelid to drop over the surface of the eye and protect it. This usually lasts 3-4 months and may help to protect the surface of the eye whilst the facial nerve recovers some function
  • Hyaluronic Acid (HA) filler injections (e.g.Restylane) into upper eyelid – HA filler can be placed through the inside of the upper eyelid to help lower a retracted upper eyelid. The filler may also act as a weight and improve eye closure and blinking

Surgical Procedures for The Eye in Facial Palsy

Surgery can improve a number of problems patients experience after a facial palsy:

Incomplete eyelid closure (lagophthalmos)

lateral tarsal strip can improve the lax lower eyelid position and tension. Click here for more information on this procedure.

medial canthoplasty can also be performed to improve closure of the inner corner of the eyelids by stitching the inner corner of the eyelids together.

lateral tarsorrhaphy (the outer parts of the upper and lower eyelids are stitched together to help closure) can be performed on a temporary or permanent basis. A permanent tarsorrhaphy tends to reserved for cases where other measures have not helped. It results in shortening of the horizontal opening of the eye and so is less satisfactory from an aesthetic perspective and can compromise the patient’s visual field.

gold or platinum weight can be implanted into the upper eyelid. This can aid upper eyelid closure significantly and can improve comfort and health of the surface of the eye. An incision through the upper eyelid skin crease and muscle is made. The weight is then stitched to the underlying tissues to secure it in position. These weights are very well tolerated and can be easily removed if facial function and eye closure were to improve at a later date. 

Brow ptosis surgery

A brow droop associated with a facial palsy can be corrected surgically if there is no significant recovery of facial function.

Click here for more information on brow ptosis surgery

Watery eye surgery

Correction of a paralytic ectropion (lax out-turning lower eyelid) can often improve watering in facial palsy patients.

Click here for more information on ectropion surgery.

Occasionally the lacrimal pump function of the eyelid muscle cannot be improved (lacrimal pump failure) despite tightening the lower eyelid and the tears fail to enter the tear drainage system. In such cases a Lester Jones tube can be inserted to drain tears directly form the corner of the eye into the nose.

Click here for more information on Lester Jones tube surgery

Mid-face Lift

This procedure can be used to support the sagging mid-face (a mid-face ptosis) and to reduce the constant downward dragging effect a mid-face ptosis exerts on the lower eyelid.

A mid-face lift can be performed by either lifting the SOOF (a layer of fat underneath the muscle) or by lifting other midface structures (including a sub-periosteal mid-face lift) with stitches to the bony rim or use of an Endotine mid-face device.

Click here for more information on mid-face lifts

Your consultation

The success and safety of your eyelid surgery procedure depends very much on your complete candidness during your cosmetic eyelid surgery consultation. You'll be asked a number of questions about your health, desires and lifestyle.

Please be prepared to discuss:

  • Why you want the surgery, your expectations and desired outcome
  • Medical conditions, drug allergies and previous medical treatments
  • Use of current medications, vitamins, herbal supplements, alcohol & tobacco
  • Previous surgeries

The following will also take place at your consultation

  • Evaluation of your general health and any pre-existing health conditions or risk factors
  • An assessment of your vision and a thorough eye examination including a slit-lamp examination of the eye.
  • Photographs for your medical record
  • A discussion about treatment options
  • Recommendations for treatment most appropriate for you
  • Discussion about likely outcomes of eyelid surgery and risks or potential complications
  • The type of anaesthesia that will be used (This is usually “Twilight anaesthesia” using local anaesthesia with intravenous sedation administered by a consultant anaesthetist. However, a full general anaesthetic can be arranged if you prefer this option)

After the consultation I will send you a letter summarising your concerns and desires relating to your appearance along with my assessment and advice to you regarding treatment options.

You will also receive a quote for your proposed surgery and have the opportunity to attend for a further consultation prior to proceeding should you wish to ask any further questions.

Arrange a consultation