Techniques in facial reanimation—upper eyelid and eyebrow

When addressing paralysis of the upper eyelid, the management options depend on the etiology and expected duration of paralysis and urgency to protect the eye. When the seventh nerve, and in particular the zygomatic branch, is compromised, the orbicularis oculi muscle is paralyzed. As a result, eyelid elevation by the Müller's muscle and the levator palpebrae superioris is unopposed, leading to relative eyelid retraction. The paralyzed orbicularis is also incapable of forced closure. The result is inability to close the eye, a condition called lagophthalmos. Typically, the eye rotates upward on eye closure, which can protect the cornea in the setting of mild lagophthalmos. This reflex upward rotation is called the Bell's response. Significant lagophthalmos (>2 mm), particularly in the presence of a poor Bell's response, can lead to exposure keratopathy and, in severe cases, corneal perforation.

In the acute setting, supportive measures including generous lubrication of the cornea is the first step in caring for the exposed eye. Frequent use (at least 6 times a day) of viscous artificial tears, gels or ointments can prevent corneal desiccation. Surgical intervention may be required in the acute setting if there are worsening symptoms and signs of corneal desiccation despite maximal medical therapy. The symptoms may be intolerable pain and/or light sensitivity and decreased vision. The signs, on slit lamp examination, include erosions of the corneal epithelium (seen with fluorescein staining at the slit lamp), as well as conjunctival hyperemia. This constellation of symptoms and signs is called exposure keratopathy.

In the acute setting, it is difficult to know how much recovery of seventh nerve function to expect. Palliative treatments to assist eyelid closure may be most appropriate until the duration and potential for seventh nerve recovery is determined. When partial recovery of function is expected, noninvasive procedures can provide temporary improvement in lagophthalmos and relief of exposure keratopathy. Options to reduce lagophthalmos include paralyzing the elevators of the eyelid, or mechanically weighting the upper eyelid to provide eyelid closure.

Botulinum toxin can be used to paralyze Müller's muscle and levator palpebrae superioris, providing complete ptosis and temporary protection to the cornea by paralyzing the upper-eyelid elevators. This technique can preferentially disable levator palpebrae superioris and Müller's muscle function without further weakening the orbicularis oculi. The technique is performed by placing a drop of topical anesthetic in the affected eye. The upper lid is everted using a cotton-tip applicator. The patient is asked to look down, to keep the cornea away from the site of injection, and the needle is aimed in a direction away from the globe (Figure 1). Botulinum toxin (10-15 U) is injected subconjunctivally, at the superior border of the tarsus, using a 30-gauge needle. The toxin is placed in immediate proximity to the levator and Müller's muscles, preferentially weakening these muscles to provide eyelid closure. Maximal effect is achieved within 5 to 7 days of injection.

An alternative to complete ptosis with botulinum toxin is temporary weighting of the upper eyelid with hyaluronic acid (HA) filler. HA is placed in the upper eyelid superior to the tarsus from an external transcutaneous approach or transconjunctival approach analogous to botulinum toxin placement described previously. The anatomic goal of placement is the superior border of tarsus at the level of the Müller's muscle and levator palpebrae superioris insertion (Figure 2). Given the close approximation of the lid and globe, the patient should be asked to look down while the eyelid is mechanically elevated superiorly. Elevation of the lid in this fashion will distract this complex from the globe, thus helping to avoid potential globe injury when using a transcutaneous approach. The direction of injection and needle placement should always be in an axis away from the eye. The amount of HA injected can be titrated based on the degree of lagophthalmos and exposure keratopathy (typically 0.4-1 mL). The transconjunctival approach is as described previously for botulinum toxin injection. The advantage of the transconjunctival approach is direct visualization. Injection of HA can provide useful reduction of upper-eyelid height and lagophthalmos for up to 1 year and is recommended for patients in whom improvement of paralysis is anticipated. In such patients, HA filler may be used as an immediate, in-office, titratable, temporizing procedure to achieve rapid improvement in corneal coverage.

Temporary tarsorrhaphy is another option for patients with temporary paralysis of the orbicularis oculi. Although there are many techniques available to achieve temporary tarsorrhaphy, the basic concept remains the same. Sutures are used to mechanically appose the lid margins at the level of the gray line. Placement of the sutures at the gray line is crucial, as this avoids posterior exposure of the sutures, which can traumatize the cornea or conjunctiva. A temporary tarsorrhaphy is ideally placed laterally, so the patient has improved corneal coverage without blocking the visual axis. The technique is typically performed using a 5-0 double-armed permanent suture. To protect the eyelid skin from the suture material, a foam or plastic bolster is placed between the suture and the skin of the upper and lower lids. A variety of materials can be used for this purpose. The foam found in suture packets and tubing from an intravenous line are readily available and inexpensive options. The technique is illustrated in Figure 3A and B. Local anesthetic is injected into the desired area. The suture needles are passed through the bolster material. The first needle is passed through the pretarsal upper-lid skin, 4 mm above the lid margin, into the tarsus. It exits at the gray line immediately posterior to the eyelashes. The second arm of the suture is passed in the same fashion parallel to the first suture, and both sutures are pulled through to bring the bolster flush against the upper-eyelid skin, abutting the lash line. The first needle is then introduced into the gray line of the lower lid directly across from the previous pass. It is driven through the tarsus and exits 4 mm below the lid margin. The same is done with the second needle, and the needles are placed through a second piece of bolster material and tied over the bolster against the lower-eyelid skin. Tarsorrhaphies placed using this technique may be left in place for approximately 1 month before causing skin breakdown.

For patients with longstanding paralysis of the upper lid, several permanent options exist for enhancing eyelid closure. These include permanent tarsorrhaphy, upper-lid weight implants, and placement of palpebral springs. Permanent tarsorrhaphy has the advantage of elevating the lower lid and lowering the upper lid, which may be useful in cases where there is lower-lid laxity or ectropion. The technique can be performed with many different nuances, but is analogous to the placement of a temporary tarsorrhaphy. The main difference is that in a permanent tarsorrhaphy, the lid margins are denuded of epithelial tissue, to promote permanent apposition. After injection of local anesthetic, blunt-tipped surgical scissors are used to mechanically denude the epithelium of the lid margin posterior to the gray line (Figure 4A). The posterior edges of the lid margins are brought together using 5-0 absorbable sutures, in a horizontal mattress fashion, to appose the denuded posterior lid margins (Figure 4B). The suture knots are tied to prevent corneal irritation (Figure 4C). Typically, a lateral tarsorrhaphy provides central closure without obscuring the visual axis, and without jeopardizing the lacrimal drainage system at the medial canthus. If lateral closure is not adequate, a permanent tarsorrhaphy may also be performed medially. This is a more challenging technique because of the presence of the lacrimal puncta in the medial aspect of the lids. The key to a successful medial tarsorrhaphy is avoiding the puncta altogether. The entire extent of the tarsorrhaphy must be placed medial to the puncta, and the passes with the absorbable suture must be shallow to avoid inadvertently puncturing the canaliculi. This technique is rarely performed. If needed, one should consider referring the patient to an oculoplastics specialist.

Permanent upper-lid weighting procedures can also aid eyelid closure analogous to injectable techniques described previously. The surgeon can use gold or platinum single-piece or chain implants. Regardless of the implant, the concept and technique are to weight the eyelid to counterbalance the resting tension of the levator and Müller's muscles and assist closure on relaxation of these muscles. In doing so, it forces the lid to close at rest, and requires the patient to engage the levator to open the eye. Eyelid closure is gravity-dependent, thus one potential pitfall to this technique is worsened lagophthalmos when the patient is supine. The amount of weight needed can be determined preoperatively using stick-on weights, and depends on orbicularis function, baseline ptosis, and function of eyelid elevators. A general surgical technique is as follows: local anesthetic is injected into the upper eyelid. At the level of the upper-lid crease, a scalpel is used to incise the skin and orbicularis oculi muscle (Figure 5A). The superior edge of the tarsus is identified, and blunt dissection on the surface of the tarsus is carried inferiorly to a point approximately 2 mm above lash line. The weight (most commonly 1.2 g) is then sewn onto the tarsus using interrupted 5-0 or 6-0 poliglecaprone or polydioxanone (PDS) suture (Figure 5B). The orbicularis is closed with 7-0 absorbable sutures, and skin is closed with 6-0 absorbable sutures (Figure 5C). The most common complications of upper-eyelid weighting are malposition and extrusion. Other potential complications include allergy or reaction to the metal placed, or placement of a suboptimal weight leading to ptosis or persistent lagophthalmos. Platinum weights were recently shown to have lower complication rates than gold weights.

Palpebral springs may be used in the treatment of upper-eyelid paralysis. They allow the eyelid to close when the levator and Müller's muscles are relaxed, and allow for dynamic facial reanimation. This technique is not as commonly performed as the aforementioned, likely owing to a combination of technical difficulty and rates of adjustment, exchange, and extrusion. A full description of this technique has recently been reviewed by Demirci and Frueh.

Several other techniques for reanimation of the lids have been reported in the literature, including primary facial nerve repair, facial nerve repair with cranial nerve motor donors, cross-facial nerve grafting, regional muscle transfers, and free muscle flaps. These are still being actively investigated and fall outside the scope of this chapter.

Elevation of the eyebrow is a direct action of the frontalis muscle, the primary muscle of the forehead. The frontalis muscle inserts and elevates the medial 2/3 of the eyebrow, and is innervated by the temporal branch of the facial nerve. The lateral 1/2 of the brow has no muscle insertion, and subsequently, the effect of gravity is unopposed, leading to the frequent lateral brow ptosis observed with advancing age. Loss of innervation to the frontalis muscle can occur due to facial nerve injury at the main trunk, upper division, or temporal branch. Proximal facial nerve injuries can occur due to multiple etiologies, including Bell's palsy, parotid tumors, acoustic neuroma or other cerebellopontine angle neoplasms, and birth trauma. Damage to the temporal branch in isolation is usually traumatic or iatrogenic due to inadvertent injury during intraoperative dissections. With both proximal and distal injuries, neurogenic brow ptosis results, with inability to raise the affected eyebrow. Management of brow ptosis in the context of facial reanimation is critical, as descent of tissues may lead to pseudodermatochalasis or subsequent mechanical eyelid ptosis, resulting in superior visual field loss and functional visual limitations.

Evaluation of a patient with brow ptosis includes assessment of the height and contour of the brow. In women, the medial eyebrow usually rests 1 cm above the superior orbital rim. The contour is more arched, with the peak classically at the level of the lateral limbus. More recently, Western fashion dictates a more lateral peak above the lateral canthus. In men, the eyebrow rests lower at the level of the superior rim, and the shape is more flat and straight. When evaluating patients preoperatively, assessment of these factors is critical so that a symmetric gender-appropriate result may be achieved.

A number of options exist for the treatment of neurogenic brow ptosis, including chemodenervation of the intact forehead, and “open” approaches such as direct, pretrichial, and coronal brow lifts. Endoscopic eyebrow lift has become a common method of eyebrow elevation, and allows for concurrent reduction of forehead furrows and glabellar rhytids while minimizing incision size and visibility. Each of these techniques may be used to treat neurogenic brow ptosis and is customized based on patient age, gender, and hairline and facial characteristics. The techniques vary with regard to length and visibility of incisions, effect on forehead rhytids and brow position, and length of procedure and recovery time. Thus a customized approach is necessary. One commonality is that despite the methodology, long-term elevation of paralytic tissues is difficult, and reoperations are the norm.

Depending on the degree of eyebrow ptosis and presence of functional limitation (eg, pseudodermatochalasis or functional ptosis), chemodenervation of the contralateral brow elevators may be a useful, minimally invasive, nonsurgical technique to regain facial symmetry. This is particularly true in younger patients with good facial tone, in whom forehead paralysis is typically only noticed during facial expressions that change the forehead appearance on the intact side. Chemodenervation is also appropriate in patients with subtle brow ptosis that does not cause functional limitation, or in patients in whom recovery of facial nerve function is anticipated. Approximately 10 to 15 U of botulinum toxin A is injected into the frontalis muscle of the unaffected side. The glabellar musculature (corrugator and procerus) can be injected with 5 to 10 U as well if they are causing facial asymmetry. Repeat injections are required every 3 to 4 months, as the effect of the toxin wears off. Botulinum toxin chemodenervation is an excellent way to address facial synkinesis after facial paralysis as well. This is discussed in more detail in a separate chapter of this issue.

For unilateral neurogenic brow ptosis, “direct” brow lift can reapproximate facial symmetry. This technique uses a suprabrow incision and, owing to its proximity to the brow, provides the greatest elevation of the brow per millimeter of skin removed. Direct brow lift is an excellent option in older patients with prominent eyebrows to camouflage the incision or in patients with a receding hairline where coronal or other scalp incisions may be noticeable. It is not optimal for women, particularly young women, in whom the scar will likely be unacceptable. Although this technique is a powerful surgical tool for brow elevation, caution must be exercised to avoid worsening preexisting lagophthalmos, especially if combined with blepharoplasty.

The direct brow lift begins with marking of the area of skin to be excised. Using a marking pen, an incision is marked adjacent to the superior eyelid hairs to facilitate a trichophytic skin closure. Next, the brow is lifted to the desired height. The marking pen is placed close to the skin, and then the brow is released. The skin below the marking pen is then marked. Multiple such measurements are taken along the length of the eyebrow. The markings are connected, forming the superior incision marking, and connected to the previously made inferior incision marking (Figure 6A). Next the area is infiltrated with extensive local anesthetic mixture. Small branches of the supraorbital and angular arteries pass to facial musculature in this region and can cause significant bleeding. Some surgeons create a geometrical-broken line incision to further mask the suture line. The incision is made with a #15 Bard Parker blade, along the previously delineated incision. At the inferior aspect of the incision, the blade is beveled away from the hair follicles to reduce the chance of postoperative alopecia. Some surgeons excise epidermis and dermis only, whereas others excise the frontalis and leave the underlying corrugator muscle to protect the supraorbital nerve, which is deep to the corrugator in this location. The ellipse of tissue is excised using either a blade or scissors, and hemostasis is achieved with bipolar cautery to minimize risk to hair follicles and nerves (Figure 6B and C). A trichophytic closure can be achieved by excising a small strip of eyebrow hair-bearing skin along the inferior aspect of the incision. The depth of incision should be maintained above the root of the hair follicles, allowing hair growth through the wound to camouflage the incision (Figure 6D). To provide the most prolonged benefit, deep 4-0 PDS sutures can be placed through the periosteum at the superior excision line, thus suspending the inferior tissue that contains the brow to a fixed structure. The superficial edges are closed using deep 5-0 monocryl sutures, with 6-0 prolene or 5-0 fast gut for the skin.

Midforehead lifting is an alternative to direct brow lift in patients with deep forehead rhytids. In brief, a transverse ellipse above the paretic brow is marked along a prominent rhytid. After the administration of local anesthesia, the ellipse is excised with a scalpel to the level of the frontalis muscle. A layered closure similar to direct brow lifting is then performed.

Transeyelid brow lift allows the surgeon to raise the eyelid through an upper-eyelid blepharoplasty incision (Figure 7), and may be used in patients with mild brow ptosis who have concurrent dermatochalasis. Careful evaluation of patients with brow ptosis should be done before considering blepharoplasty, as brow ptosis may lead to pseudodermatochalasis, which corrects when the brow is lifted into a physiological position. In patients with dermatochalasis contributing to functional superior visual field limitation, this approach addresses both the upper eyelid and brow. The procedure begins by marking the upper-eyelid crease and the ellipse of tissue to be removed if upper-eyelid blepharoplasty is planned. Next, local anesthetic is injected into the upper eyelid and brow. Using a #15 Bard Parker blade, a skin incision is made along the previously demarcated line, and an ellipse of skin tissue is removed. Due to existing orbicularis paralysis, care should be taken to avoid orbicularis excision. The dissection is carried superiorly, anterior to the septum extending beyond the superior orbital rim at least 2 to 3 cm. The sub-brow tissues are then fixated to the periosteum of the superior orbital rim. The upper-eyelid incision is then closed using running 6-0 fast-absorbing gut or prolene sutures. Variations of brow fixation exist and include the use of permanent sutures to fixate to periosteum, as well as the use of Endotine (MicroAire, Charlottesville, VA) or other biodegradable fixation devices. Advantages of this technique include the use of a single incision to address both upper-eyelid skin and brow position, while obviating more noticeable scars above the brow or in the forehead. It is difficult to address moderate or severe brow ptosis with this technique, necessitating careful patient selection.

With the advent of endoscopic techniques for forehead lifting, open approaches are less commonly used. However, open approaches offer more control over the postoperative hairline, and may enable more exact fine-tuning of the brow position. Open techniques allow direct visualization of corrugator and procerus muscles, and neurovascular bundles. The coronal and pretrichial approaches are the two most representative open techniques. The coronal lift incision is made posterior to the hairline, and skin is excised in the hair-bearing scalp (Figure 8A). This elongates the forehead, making it less optimal for patients with high or receding hairlines. In the pretrichial approach, the incision is placed at the anterior hairline with excision of forehead skin. This leaves the hairline unchanged or even lowers it slightly, making it well-suited for patients with high hairlines (Figure 8B). These techniques are rarely used to address the forehead in patients with facial paralysis, and a complete discussion of open aesthetic forehead surgery techniques is beyond the scope of this discussion.

Endoscopic brow lifting provides an excellent way to elevate the brow while minimizing incision size and visibility. In patients with facial paralysis, it can be performed “asymmetrically” on both sides to simultaneously restore brow symmetry and address forehead aging, making it particularly useful for middle-aged older patients. Traditionally, in bilateral endoscopic brow lifting, five vertical incisions are made in the hair-bearing scalp: one central, two paramedian, and one in each temple (Figure 9). Paramedian incisions should be made between the midpupillary line and lateral canthus, depending on the desired location of the brow peak. The procedure can be done either under general anesthesia or monitored anesthesia care. In brief, this technique begins by marking the incisions followed by administration of local anesthetic with epinephrine to each of the incision sites. Tumescent anesthesia can be injected into the forehead and at the level of the brows to facilitate the dissection and enhance hemostasis by creating a “vascular tourniquet.” The temporal incisions are made to the temporalis fascia, thus minimizing risk of injury to the temporal branch of the facial nerve as the dissection proceeds anteriorly. The more medial incisions—and the major plane of dissection—can be subperiosteal or subgaleal; we perform subperiosteal dissection at our institution. Using an endoscope and an elevator, the forehead is dissected to the level of the superior orbital rims, making sure to preserve the supraorbital and supratrochlear neurovascular bundles. Temporally, dissection is carried out over the temporalis fascia, and is connected with the central dissection by releasing the conjoint tendon. The corrugator muscles can be cauterized or partially resected to reduce deep glabellar rhytids. If performed unilaterally, a midline galeotomy should be considered to allow elevation of the paretic brow without affecting the intact side. Once adequate release of periosteal attachments has been performed, the forehead is advanced superiorly. Temporally, tissues are suspended to the deep temporalis fascia with 3-0 PDS suture. The forehead can be suspended at the paramedian incisions using multiple techniques, including absorbable and nonabsorbable screws, Endotine fixation devices, and bone tunnels with suture fixation. The fixation method chosen should maintain suspension for at least 12 weeks, as periosteal reattachment takes 6 to 12 weeks. Skin incisions in hair-bearing areas are closed using skin staples, which are removed in 7 to 10 days.