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Facial palsy is a weakness or loss of function of the facial nerve and forehead, eyelid, cheek and lip function are affected. Approximately, 1 in 60 people over their lifetime will develop the condition. If the upper branches of the facial nerve are involved, the eyelids are unable to close fully and protection of the eye surface is compromised.

What are the causes of facial palsy?

Often facial palsy is self-limiting and not associated with any other particular conditions (Bell’s palsy), although virus such as the cold-sore virus and shingles are thought to play a role. Your doctor may give you a short course of oral anti-viral tablets and steroids, but usually a Bell’s palsy will start to resolve within a matter of weeks. In some instances, particularly after surgery for certain head tumours or after stroke, the facial palsy will be permanent.

What are the symptoms of facial palsy?

Symptoms include a sore red eye, watery eye, reduced vision, conjunctival or corneal infections, lower lid out-turning (ectropion), eyebrow droop, cheek drooping, lip biting, mouth drooling, inability to smile on one side and distressing facial asymmetry.

How is facial palsy diagnosed?

Your doctor will be able to diagnose this condition from examining you clinically. You may be asked to get an MRI scan of the head or blood tests if there are other associated features that link to other conditions.

How is facial palsy treated?

Whether temporary or permanent, the main priority of treatment is protection of the eye surface and thus vision. You will need to apply frequent eye lubricating drops and ointment and ensure the eyelid is closed at nighttime when you sleep, either with tape or padding of the eyelid. If eyelid closure is not recovering, then surgical options to aid eyelid closure exist.

Surgery for eyelid closure includes a lateral tarsorraphy (pinching of the upper and lower eyelids together at the outer corner, but this narrows the size of the eyelid aperture/appearance of the eye), or an upper lid weight implant with a lower lid tightening procedure. Eyelid weights are made in gold, platinum, solid or chain formats and are buried under the upper eyelid skin. They aid the eyelid to close, almost normally, when the person decides to close their eyelids. The resting blink reflex remains reduced despite the weight. They allow a more normal appearance of the eyelid whilst protecting the eye surface.

Unfortunately, one of the biggest difficulties with facial palsy is the reduced tone in the lower eyelid and thus the eyelid does not drain tears efficiently. Often a patient has a watery eye that affects daily function. Surgery to improve the lower eyelid position and tightness aids this, but often the patient will need more than one procedure to minimize the symptom sufficiently.

As the brow and cheek also droop, these may need correction. The lower lid position is very dependent on the cheek position and a persistently watery eye may be due to the lack of cheek tone and pulling of the lower eyelid down centrally with gravity. Borrowing spare tendon tissue from the thigh and using this for a cheek sling can support the cheek and midface, and thus the eyelid. Other options include nerve grafting over a couple of procedures.

What are the complications of surgery?

As with any eyelid surgery, there is a small risk of scar, infection, bruising, need for further surgery, visual blurring or difficulty with eyelid closure. In addition, if a weight is placed in the upper eyelid, there can be associated change to your astigmatism and alter your glasses prescription slightly. As they are an implant, they carry the risk of working their way out the eyelid and needing further surgery to correct this. Lower eyelid surgery aims to reduce the watery eye symptoms but this can still remain post procedure and further surgical options may need to be explored. Facial palsy causes facial asymmetry of appearance. This is usually improved after surgery but there is usually some asymmetry still present. The main priority is protection of the eye surface and thus vision, and occasionally the eyelid appearance needs to be narrowed in order to preserve this.

What can I expect during and after surgery?

Your surgeon will guide you through the necessary procedures. Most procedures are done under local anaesthetic (awake) to numb the eyelids and face but you can have sedation to be made drowsy if you wish. You will be able to close your eyes during the procedure. General anaesthetic options (fully asleep) are also possible. After surgery, you will need to see your Specialist for stitches to be removed at around 1 week. You will be given antibiotic cream to use twice daily to the wounds and sometimes a course of oral antibiotic tablets.

What are the long-term effects of facial palsy?

With time, a weak face will develop contractures or tightening and sometime abnormal neighbouring nerves will affect the weak muscles. This can lead to spasms of the side of the face. Careful use of muscle relaxants to reduce these contractures and spasms can be beneficial.