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return to: Facial Paralysis (surgery for facial nerve paralysis weakness)

Platinum-Gold eyelid weighting (Corneal eye protection for Facial Paralysis)

Case examples provided by Dr. Douglas Henstrom, Director of University of Iowa Facial Plastic and Reconstructive Surgery and Facial Nerve Center, Department of Otolaryngology
For appointment please call: 319-356-3600

GENERAL CONSIDERATIONS

1. Facial nerve paralysis resulting in lagophthalmos can result in the loss of corneal protection. This can lead to significant sequela including exposure keratitis, corneal ulceration, and potentially permanent vision loss. Although gold weight loading of the upper lid has shown to be an effective solution for this problem, more recently, the use of platinum weights has gained in popularity. As this material is of a higher density, a similar weight may be placed with a smaller profile providing for less lid bulk. The smaller weight also cuts down on both the rate of migration and extrusion. A recent study demonstrated no post-operative inflammation or infection with placement of these weights.
2. Other recent studies have shown the significant improvement in quality of life with proper management of the periocular complex in facial paralysis. Thus placement of a weight may be considered even if in a temporary situation while a patients facial nerve fully recovers from an insult.
3. Informed consent should discuss very low chance of loss of vision, infection, hematoma, ecchymosis, and possible development of astigmatism (correctable by removal of weight). Patients with previous radiation are at particular risk for extrusion.
4. Procedure is easily reversible, by removing the weight, in cases of return of eyelid function.

PREOPERATIVE PREPARATIONS

1. The patient must be examined pre-operatively to determine the most appropriate sized weight to use. This is achieved by fixing a series of weights that vary in 0.2 gram increments to the upper lid with adhesive. The patient should be able to achieve complete eye closure with the weight centered on the medial limbus. This should be balanced to ensure that excessive lid ptosis does not occur. The patient should be allowed to wear the weight for at least 15 minutes to ensure comfort and sizing, including time while lying down to ensure adequate eye closure in that position.
   1. Once the correct weight is selected, the supratarsal crease should be marked prior to injection.

NURSING CONSIDERATIONS

ANESTHESIA CONSIDERATIONS

1. This procedure is generally tolerated under local anesthesia in itself. If this is performed as part of a separate procedure, MAC or general anesthesia may be used as appropriate.
   1. The size of weight must be selected prior to administration of any anesthetic or sedatives.

OPERATIVE PROCEDURE

1. The patient is then transferred to the location of the procedure, and a time out is performed. 1% Lidocaine with 1:100,000 Epinephrine is injected into the upper lid.
2. A 2 to 2.5 cm incision is created in the supratarsal crease of the upper eyelid. This incision line is approximately 10 mm from the inferior margin of the upper lid. 
   1. The incision is carried through the orbicularis oculi, down to the level of the superficial surface of the tarsal plate. The orbital septum is not violated.  
      1. A small pocket is then created between the Orbicularis oculi muscle and the tarsal plate.  This should extend inferiorly above the free margin of the eyelid to help prevent protrusion.  
   2. The implant is centered over the medial limbus, and is secured using 6-0 clear nylon sutures in 3 point fixation through all plate holes, placed partial thickness through the tarsal plate.
      1. The suture is placed partial thickness horizontally through the tarsal plate. The lid is elevated, with pressure placed downward on the needle, and the underside of the upper eyelid is inspected to ensure that the needle has not been passed too deeply through the conjunctiva.
         1. The suture is then passed through the hole on the weight and tied inferiorly (x2 on bottom), or superiorly (x1 on top) to secure the weight.  
   3. The orbicularis oculi muscle are then repaired with two buried interrupted 5-0 Vicryl sutures.  
   4. The skin layer is then closed using 6-0 or 7-0 nylon sutures that can be removed on postop day 5. Alternatively 5-0 fast absorbing suture may be used.

POSTOPERATIVE CARE

1. Half strength hydrogen peroxide on q-tips is used to clean the incision BID.
2. Cleaning is followed by the placement of Erythromycin Ophthalmic ointment to the suture line BID.
3. Patients should return at two weeks for further evaluation (or 5 days for suture removal). 
4. Of note, patients with platinum or gold weights may undergo an MRI.

REFERENCES

Lavy JA, East CA, Bamber A, Andrews PJ. Gold weight implants in the management of lagophthalmos in facial palsy. Clin Otolaryngol Allied Sci. 2004 Jun;29(3):279-83.

Silver AL, Lindsay RW, Cheney ML, Hadlock TA.  Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg. 2009 Jun;123(6):1697-703.

Jelks, G. W., Smith, B., and Bosniak, S. The evaluation and management of the eye in facial palsy. Clin. Plast. Surg. 6: 397, 1979.

Choi HY, Hong SE, Lew JM.  Long-term comparison of a newly designed gold implant with the conventional implant in facial nerve paralysis. Plast Reconstr Surg. 1999 Nov;104(6):1624-34.

Seiff, S. R., Sullivan, J. H., Freeman, L. N., and Ahn, J. Pretarsal fixation of gold weights in facial nerve palsy. Ophthal. Plast. Reconstr. Surg. 5: 104, 1989.

Chepeha DB, Yoo J, Birt C, Gilbert RW, Chen J. Prospective evaluation of eyelid function with gold weight implant and lower eyelid shortening for facial paralysis. Arch Otolaryngol Head Neck Surg. 2001;127:200. Commentary Arch Facial Plast Surg. 2002;4:60.

Henstrom DK, Lindsay RW, Cheney ML, Hadlock TA. Surgical Treatment of the Periocular Complex and Improvement of Quality of Life in patients with Facial Paralysis. Arch Facial Plast Surg. 2011 Mar-Apr;13(2):125-8.