Ophthalmic Management of the Facial Palsy Patient

Transcription

1 Ophthalmic Management of the Facial Palsy Patient Philip L. Custer, M.D. 1 ABSTRACT The management of the ocular sequelae of facial palsy should be individualized for each patient. The patient s age, ocular motility, tear production, and corneal sensation are considered when developing a treatment plan. Individuals with transient weakness often require only therapy with topical lubricants. Permanent or chronic facial paralysis is usually associated with lagophthalmos, ectropion, and exposure keratitis. Both static and dynamic procedures can be performed to improve these conditions. Combined eyelid surgery and suspension of the midface often provides the best result. However, patients with permanent facial palsy usually suffer chronic ocular symptoms, requiring long-term follow-up and continued topical therapy. KEYWORDS: Lagophthalmos, paralytic ectropion, exposure keratopathy The muscles innervated by the facial nerve are essential in maintaining ocular health and cosmesis. Patients with facial weakness often develop long-term functional and aesthetic eyelid deficits. Absent orbicularis muscle tone results in a widened palpebral fissure. The loss of active orbicularis contracture limits blinking and eyelid closure, contributing to an asymmetrical facial appearance. It is remarkable that some patients tolerate marked lagophthalmos with minimal ocular symptoms, whereas other individuals with lesser degrees of incomplete eyelid closure develop severe exposure keratopathy, corneal ulceration, and visual loss. A variety of factors determine the impact of facial palsy upon ocular comfort and health. The clinician should consider the patient s age, corneal sensation, ocular motility, and tear production when developing a treatment plan for the patient with facial paralysis. Patient s Age In general, younger patients better tolerate lagophthalmos. The excellent eyelid tone of youth helps maintain close approximation of the lower lid to the globe, minimizing the widened palpebral fissure that usually accompanies facial weakness. Eyelid laxity increases with age. Ectropion and downward displacement of the lower eyelid appear after loss of orbicularis function in patients with preexisting laxity. Tear production usually declines with advancing age, contributing to the corneal desiccation associated with lagophthalmos. Elderly or debilitated patients may have difficulty instilling ocular lubricants, increasing their risk of exposure keratitis. Older individuals develop more marked eyebrow ptosis following facial palsy. Corneal Sensation The afferent sensory arm of the corneal blink reflex is mediated by the nasociliary nerve, a branch of the trigeminal nerve (cranial nerve V1). Deficits of this nerve result in corneal hypesthesia, a condition that significantly increases the likelihood that a patient with lagophthalmos will develop keratopathy. Other conditions associated with decreased corneal sensation include Facial Paralysis; Editor in Chief, Saleh M. Shenaq, M.D.; Guest Editor, Susan E. Mackinnon, M.D. Seminars in Plastic Surgery, Volume 18, Number 1, Address for correspondence and reprint requests: Philip L. Custer, M.D., Department of Ophthalmology, Washington University School of Medicine, 660 S. Euclid Avenue, Box 8096, St. Louis, MO Department of Ophthalmology and Visual Sciences, Washington University, St. Louis, MO. Copyright # 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY USA. Tel: +1(212) ,p;2004,18,01,031,038,ftx,en;sps00106x. 31

2 32 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER diabetes, prior herpetic infection, and previous ocular or refractive surgery. Even in the presence of corneal erosion or infection, patients with corneal hypesthesia experience little discomfort and are often unaware of the severity their keratopathy. Unrecognized lagophthalmos can cause rapidly progressive corneal decompensation in sedated or comatose patients because of the reduced blink reflex. Ocular Motility Bell s phenomenon is a protective reflex that rotates the globe upward during periods of eyelid closure. Patients with absent or incomplete Bell s phenomenon are much more likely to develop corneal exposure following facial palsy. The normal excursions of the globe assist in maintaining a uniform tear film in the presence of lagophthalmos. Many patients with facial palsy either consciously or subconsciously lubricate their corneas by periodically gazing peripherally, using the static eyelids to spread tears across the moving cornea. Cranial neuropathies or other conditions interfering with ocular movement may exacerbate keratopathy, particularly if the globe is fixed in primary gaze. Lacrimal Production The parasympathetic innervation of the lacrimal gland travels within the nervus intermedius, adjacent to the motor division of the facial nerve. Insults to this portion of the facial nerve can lower tear production and cause a dry eye, increasing the keratopathy associated with facial weakness. Tearing is a common symptom in patients with facial palsy. An intact orbicularis muscle is needed for adequate lacrimal drainage. Contracture of this muscle assists in creating a pumping mechanism, forcing the tears through the lacrimal canaliculi. This pump is not functional in patients with facial weakness, making the lacrimal drainage system ineffective. Episodic tearing can be related to reflex hypersecretion in response to corneal dryness. Individuals with partial recovery of facial paralysis may experience tearing while chewing because of aberrant reinnervation of the lacrimal gland. Facial palsy patients with symptomatic epiphora should be informed that this symptom often persists despite eyelid surgery. One study found that tearing was unchanged (42%) or only partially improved (36%) in most patients after treatment. 1 OPHTHALMIC MANAGEMENT OF THE FACIAL PALSY PATIENT An ophthalmologist should evaluate all patients with facial palsy and lagophthalmos. The slit lamp biomicroscope is used to determine corneal integrity. Schirmer s testing can be performed to measure lacrimal production. In cases of transient facial weakness, topical lubricants and nighttime occlusion may be sufficient to maintain corneal integrity until lid function recovers. Increasing environmental humidity helps reduce symptoms in patients living in regions with extremely dry air. Lubricating or antibiotic ointment can be instilled every several hours in patients with, or at risk for, keratopathy. A variety of shields and moisture chambers are available for either full- or part-time ocular occlusion. Temporary tarsorrhaphy sutures can be extremely helpful in providing immediate eyelid closure, delaying the need for more definitive procedures. Botulinum toxin can be used to lower the upper eyelid transiently. The lid typically drops several days after injecting the levator muscle. It can require several months for the induced ptosis to resolve. Patients with chronic facial weakness usually require eyelid surgery to improve lid function and corneal protection. Surgical treatment should be individualized, choosing the technique that best addresses each patient s findings. The procedures employed can be divided into static operations that alter the palpebral fissure size and dynamic procedures intended to improve eyelid mobility and closure. Medial canthoplasty and partial lateral tarsorrhaphy narrow the palpebral fissure in both the horizontal and vertical dimensions and also assist in suspending the lower lid. More extensive central or lateral tarsorrhaphies are reserved for patients with inadequate Bell s phenomenon, poor tear production, or neurotrophic keratopathy. These techniques usually result in a grossly abnormal appearing palpebral fissure and obstruction of visual field. Lower eyelid surgery is indicated in patients with ectropion or significant lower eyelid retraction. The lateral canthal sling or its modification, the tarsal strip procedure, is effective in tightening and suspending the lid. 2,3 Although lower eyelid malposition is usually caused by horizontal laxity, some patients have a cicatricial component secondary to marked sagging of the cheek or a vertical shortage of lower eyelid skin. A fullthickness skin graft or cheek (suborbicularis oculi fat [SOOF]) lift can be combined with the tarsal strip procedure in such cases. SOOF lifting appears to be most effective and long lasting in patients with thin cheek tissue. 4 Patients with prominent eyes or flat cheeks often develop lower eyelid retraction that is difficult to improve completely with horizontal eyelid tightening. Semirigid posterior lamellar grafts, such as hard palate or cartilage, can be used to elevate the retracted lid. 5 Alternatively, a porous polyethylene implant can be placed within the lower lid to act as a scaffold above the inferior orbital rim. Unfortunately, alloplastic eyelid implants can become exposed and probably should be reserved for patients not responding to traditional techniques. Cheek augmentation can occasionally be

3 OPHTHALMIC MANAGEMENT OF THE FACIAL PALSY PATIENT/CUSTER 33 helpful in patients with poor malar support of the lower lid. Levator aponeurotic recession can be used to lower the upper eyelid, a procedure that is easily combined with gold weight insertion. Elevating a ptotic brow improves facial symmetry. However, the weight of the drooping brow occasionally assists eyelid closure. Some patients exhibit more marked lagophthalmos after brow lift. Several procedures have been developed to achieve dynamic eyelid closure in patients with paralytic lagophthalmos. Lalardrie and Morel-Fatio first popularized the use of a metallic palpebral spring. 6 Stainless steel wire is fashioned intraoperatively to create a spring. The upper arm of the implant is attached to the periosteum of the superior lateral orbital rim, while the lower arm is passed across the upper lid in the pretarsal plane. The spring closes the lid upon levator relaxation. There have been numerous modifications of the original technique in an effort to reduce complications, such as loosening of the periosteal fixation and erosion of the inferior arm of the spring through the eyelid skin. May was able to improve success by using 0.3-mm orthodontic wire and wrapping the pretarsal spring with Dacron. 7 However, among 101 patients observed for less than 41 months, 14 implants were removed or extruded and 10 required replacement. May has further modified his technique in an effort to elevate the lower lid mechanically as well. 8 The elbow of the spring is fixated to the orbital rim, while the two arms of the spring are individually inserted into the upper and lower lids. McNeill and Oh reported results in 24 patients in whom the upper arm of the spring was wired to the orbital rim and a Dacron sleeve was used to wrap the distal end of the lower arm of the spring. 9 During an average 3 year follow-up, 42% of patients required some form of adjustment or secondary repair. Four springs were removed because of extrusion or infection. Arion achieved dynamic eyelid closure in patients with facial palsy by encircling the palpebral fissure with a subcutaneous elastic silicone thread. 10 Several complications were associated with this procedure, including loss of elasticity, breakage, infection, and erosion of the implant through the eyelid skin. Other surgeons have modified the operation, using fascial bands to both suspend the lower eyelid and increase the horizontal tension of the upper eyelid, improving closure upon levator relaxation. 11,12 Similarly, the natural elasticity of the tarsal plates can be used to improve closure by tightening the upper and lower lids with lateral tarsal strip procedures. Combined static and dynamic eyelid closure can be achieved with the temporalis muscle transfer procedure. Flaps of temporalis fascia are transposed and tunneled across the upper and lower eyelids. Voluntary contracture of the temporalis muscle increases the tension of the flaps, closing the lids. Ueda et al compared the results of this procedure with lid loading, finding similar symptomatic relief with both operations. 13 However, the muscle transfer was more likely to achieve full eyelid closure. One drawback of temporalis transfer is involuntary eyelid closure while eating. Insertion of a weight into the upper eyelid can improve eyelid closure by gravitational forces. In 1966 Smellie reported the successful insertion of a lead weight in a single patient, suggesting that gold might be the most ideal metal for eyelid implantation. 14 Since then, there have been numerous reports outlining the use of gold eyelid weights. In a survey of more than 2000 implants, Jobe reported an approximate extrusion rate of 2.6%. 15 Harrisberg and colleagues compared the results of gold weights both with and without fixation to the anterior tarsal surface. 16 Patients with unsutured weights were more likely to be dissatisfied with their cosmetic appearance. These weights were more likely to migrate toward the lid margin, where they were both more noticeable and prone to extrusion (Fig. 1). However, the inferior position of the migrated weights did facilitate eyelid closure. Another group of authors confirmed a significantly higher rate of implant exposure or extrusion (p ¼ ) if the weight was not sutured to the tarsus. 17 Prior eyelid surgery has been shown to be associated with a higher incidence of implant exposure. 17,18 A prospective study demonstrated that although gold weight insertion improved eyelid closure and visual acuity, blinking remained inadequate and a majority of patients continued to use topical lubricants after surgery. 19 Despite the low reactivity of gold, selected patients can develop an inflammatory reaction to the implant, manifested by persistent eyelid edema and erythema (Fig. 2). 20 This complication occurred in 12% of the patients reported by Seiff and colleagues. 21 The inflammation may respond to a local steroid injection. Implant removal may otherwise be necessary. Platinum implants are now available for patients thought to be sensitive to gold. Although magnetic resonance Figure 1 Migrated gold weight extruding through the upper eyelid skin.

4 34 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER Figure 2 Left upper eyelid inflammation secondary to gold weight implantation. Figure 3 Temporary suture tarsorrhaphy using 4-0 silk mattress sutures passed through segments of butterfly tubing. imaging may cause movement of steel eyelid springs, this study can by safely performed in patients with gold weights. 22 In a retrospective study of 211 patients, Lisman et al found that static eyelid surgery was more effective in reducing ocular symptoms with fewer complications than dynamic procedures such as Arion slings and palpebral springs. 23 However, this study included only three patients in whom eyelid weights had been inserted. Combining eyelid static surgery with suspensory procedures of the midface improved the longevity of treatment and reduced the need for reoperation. Reinnervation procedures that improve orbicularis tone are also likely to improve the long-term stability of the eyelids. Patients with aberrant regeneration of the facial nerve experience a variety of ocular symptoms. The palpebral fissure is often narrowed from increased orbicularis tone. A noticeable wink can occur in conjunction with eating or other facial movement. So-called crocodile tears appear while eating secondary to aberrant stimulation of the lacrimal gland. Limited ptosis repair or botulinum toxin injection can be used to counteract the increased orbicularis contracture, although either of these procedures may exacerbate lagophthalmos. Directly injecting the lacrimal gland with botulinum toxin has been reported to reduce excessive tear production. 24 SELECTED SURGICAL TECHNIQUES Tarsorrhaphy Suture Infiltrative anesthesia is administered to the upper and lower eyelids. A double-armed 4-0 silk suture is passed in a mattress fashion from the skin through both eyelid margins. Segments of butterfly tubing (4 mm in length) are used as bolsters to prevent suture erosion through the eyelid skin. Care is taken before tying the sutures to ensure that no lashes are inverted. Two to four sutures are typically placed, depending upon the need to instill medication or examine the globe (Fig. 3). Topical antibiotic ointment is applied to the sutures several times each day. Although these sutures can occasionally be left in place for several months, most eventually start to erode the eyelid skin, indicating the need for suture removal. More transient eyelid closure can be achieved with an absorbable 6-0 chromic suture that is externalized on the lower lid but buried in the upper eyelid margin. This suture enters the lower lid skin several millimeters below the lash line, exiting the central lid margin. A horizontal mattress bite is then taken through the central upper lid margin. The suture is then passed back through the lower lid margin to exit on the skin, where it is tied. Permanent A permanent tarsorrhaphy should start at the lateral canthus. The length of tarsorrhaphy is determined by the degree of lid closure necessary to control the patient s symptoms. Some patients require only several millimeters, but in others complete closure of the palpebral fissure is beneficial. Infiltrative anesthesia is administered to the upper and lower eyelids. Marginal blepharotomies are performed several millimeters in depth, dividing the lid into anterior and posterior lamella. It is essential that the incision be placed such that the lash follicles are contained within the anterior flap. The mucosa of the posterior lid margins is removed. In patients with relatively wide lid margins a buried double running 6-0 chromic suture can be used to join the two lids. Starting temporally, the suture is passed partial thickness through the edge of the posterior flap, ensuring that no suture material is exposed on the posterior eyelid surface. The running suture is reversed at the nasal end of the tarsorrhaphy. It is then used to suture the deep surface of the anterior flaps before being tied near the lateral canthus. If necessary, additional 7-0 chromic sutures can be passed through the skin edges. Mattress 5-0 silk sutures tied over bolsters may be used to approximate the flap edges in patients with thin lid margins.

5 OPHTHALMIC MANAGEMENT OF THE FACIAL PALSY PATIENT/CUSTER Figure 4 Medial canthoplasty. (A) A mucocutaneous incision has been created around the canthal angle. (B) The conjunctival mucosa of medial canthus has been excised. (C, D) Upper and lower arms of medial canthal tendon are joined with 6-0 Vicryl sutures. (E) Skin closure with 6-0 fast absorbing gut sutures. Medial Canthoplasty A modification of the procedure described by Lee is effective in closing the medial canthal angle (Fig. 4).25 The medial upper and lower lids are injected with local anesthetic. Incisions are created at the mucocutaneous junction of the eyelids, starting 1 to 2 mm medial to the puncta and extending to join in the canthal angle. The skin of the upper and lower lids is undermined for several millimeters from the incisions. Lacrimal probes may be used to identify and protect the adjacent canaliculi as the conjunctival mucosa is excised posterior to the incisions, exposing the deep surface of the medial canthal tendon. Buried 7-0 Vicryl sutures are used to join the upper and lower tendons, closing the medial canthal angle, taking care to avoid the canaliculi. The skin flaps are advanced and sutured with either 6-0 fast-absorbing gut or 7-0 Prolene sutures (Fig. 5). Lateral Tarsal Strip Infiltrative anesthetic is injected into the lateral eyelids and lateral canthus. A 10- to 15-mm lateral canthotomy is performed, dividing the canthal tendon into upper and lower arms. The inferior lateral canthal tendon is disinserted from the orbital rim. The periosteum of the inner and outer rim is exposed. Bipolar cautery is usually needed to control minor bleeding from several small vessels adjacent to the inner periosteum. The lower lid is drawn laterally to determine the necessary amount of horizontal tightening. Excessive lid shortening should be avoided in patients with prominent eyes or flat inferior orbital rims to prevent drawing the eyelid underneath the globe. The tarsal strip usually measures 4 to 7 mm in length. An infraciliary incision is created just below the lash line and the skin and preseptal orbicularis muscle are elevated. A marginal blepharotomy is performed, and 35

6 36 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER Figure 5 A patient with facial palsy (A) before and (B) after medial canthoplasty and lateral tarsal strip procedure. the fibrous eyelid strut containing the eyelashes is excised off the tarsus. The remaining mucosa of the lid margin is then removed. An incision is created below the tarsus, dividing the conjunctiva and lower eyelid retractors. Finally, the conjunctiva adherent to the tarsus is ablated with light bipolar cautery. Throughout the dissection, care is taken to preserve the tarsus. A mattress doublearmed 5-0 Prolene suture is used to attach the distal tarsal strip to the inner periosteum of the lateral orbital rim. The height of this attachment determines the position and contour of the lower lid and canthal angle. The suture is angled superiorly so that it exits on the outer edge of the periosteum at a higher level than its entrance. The exit site is usually several millimeters above the canthal angle. Failure to attach the strip to the inner periosteum contributes to decreased apposition of the lateral lower lid to the globe. A buried 6-0 Vicryl suture is used to join the tarsal strip to the upper canthal tendon, reforming the canthal angle. The canthotomy is closed in a layered fashion (Fig. 5). It is usually best not to perform extensive blepharoplasty with the tarsal strip procedure in patients with facial palsy because of the lid retraction that is occasionally associated with skin or fat resection. The tarsal strip procedure is easily combined with lower eyelid skin grafting or cheek lift in patients with cicatricial lower eyelid ectropion or retraction. Full- thickness skin grafts are placed overlying the preseptal orbicularis muscle via an infraciliary incision across the eyelid. Cheek lift is usually performed through a conjunctival incision (Fig. 6). The cheek can be advanced through either a sub- or preperiosteal dissection. The cheek is fixated to the arcus marginalis of the inferior orbital rim and periosteum of the zygoma. Holes may be drilled in the orbital rim to facilitate suture suspension in patients with attenuated periosteum. Hard palate, tarsal, or donor (sclera, acellular dermis) posterior lamellar grafts can be used to elevate the lower lid further in patients with prominent eyes and flat, recessed cheeks. The same patients occasionally benefit from malar implants, which provide additional support and elevation of the lower lids. Gold Weight Implantation Prior to surgery, the patient is placed in a sitting position and sizing implants are used to determine the appropriate weight. The implant is taped to the pretarsal upper eyelid. The ideal sized weight should provide maximal eyelid closure without excessive ptosis. Hontanilla thought that the implanted weight should be 0.2 g heavier than the ideal cutaneous sizing implant, compensating for differences in force vectors between the two locations.26 The upper lid is anesthetized and an Figure 6 Combined paralytic and cicatricial ectropion (A) before and (B) after lateral tarsal strip procedure and SOOF lift. Future gold weight implantation is planned.

7 OPHTHALMIC MANAGEMENT OF THE FACIAL PALSY PATIENT/CUSTER Figure 7 Gold weight insertion. (A) The incision is marked in the upper eyelid crease. (B) The orbicularis and aponeurosis have been incised, exposing the tarsal surface. (C) The gold weight is sutured prior to being inserted anterior to the tarsus. (D) The levator aponeurosis has been closed over the weight. (E) Skin closure with 6-0 fast-absorbing gut. eyelid crease incision is created across the central lid (Fig. 7). Dissection is carried down to the levator aponeurosis, which is divided several millimeters above the superior tarsal edge. The aponeurosis is then elevated off the aponeurosis and superior two thirds of the tarsus. Most implants are fenestrated, allowing suture fixation to the tarsus. Polyester (6-0) sutures are passed through the medial and lateral fenestrations to help prevent inferior migration of the implant. The lid should be everted and inspected to ensure that these sutures are not exposed on the posterior lid surface. The levator aponeurosis can be recessed to lower the eyelid further in patients exhibiting excessive lagophthalmos. Otherwise the aponeurosis, orbicularis muscle, and skin are closed in separate layers. Migrated, exposed, or infected weights require repositioning or removal. Some patients develop a chronic inflammatory reaction to the gold implant. Special order platinum weights may be better tolerated in such individuals. CONCLUSION The treatment of lagophthalmos and exposure keratopathy should be individualized for each patient with facial weakness. A variety of techniques may be used to improve lid function and ocular comfort. Ancillary surgery, such as facial suspensory or reanimation procedures, can also be helpful. Despite these measures, many 37

8 38 SEMINARS IN PLASTIC SURGERY/VOLUME 18, NUMBER patients with facial palsy remain symptomatic. Frequent ophthalmic evaluations and the lifelong use of topical lubricants are often needed. REFERENCES 1. Leatherbarrow B, Collin JRO. Eyelid surgery in facial palsy. Eye 1991;5: Tenzel RR, Buffam FV, Miller GR. The use of the lateral canthal sling in ectropion repair. Can J Ophthalmol 1977;12: Anderson RL, Gordy DD. The tarsal strip procedure. Arch Ophthalmol 1979;97: Oliver JM. Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy. Br J Ophthalmol 2000;84: May M, Hoffmann DF, Buerger GF, Soll DB. Management of the paralyzed lower eyelid by implanting auricular cartilage. Arch Otolaryngol Head Neck Surg 1990;116: Morel-Fatio D, Lalardrie JP. Palliative surgical treatment of facial paralysis. The palpebral spring. Plast Reconstr Surg 1964;33: May M. Gold weight and wire spring implants as alternatives to tarsorrhaphy. Arch Otolaryngol Head Neck Surg 1987; 113: May M. Paralyzed eyelids reanimated with a closed-eyelid spring. Laryngoscope 1988;98: McNeill JI, Oh Y. An improved palpebral spring for the management of paralytic lagophthalmos. Ophthalmology 1991;98: Arion HG. Dynamic closure of the lids in paralysis of the orbicularis muscle. Int Surg 1972;57: Gilliland GD, Wobig JL, Dailey RA. A modified surgical technique in the treatment of facial nerve palsies. Ophthal Plast Reconstr Surg 1998;14: Wiggs EO, Guibor P, Hecht SD, Wolfley DE. Surgical treatment of the denervated or sagging lower lid. Ophthalmology 1982;89: Ueda K, Harii K, Yamada A, Asato H. A comparison of temporal muscle transfer and lid loading in the treatment of paralytic lagophthalmos. Scand J Plast Reconstr Surg Hand Surg 1995;29: Smellie GD. Restoration of the blinking reflex in facial palsy by a simple lid-load operation. Br J Plast Surg 1966;19: Jobe R. Gold lid loads. Plast Reconstr Surg 1993;91: Harrisberg BP, Singh RP, Croxson GR, Taylor RF, McCluskey PJ. Long-term outcome of gold eyelid weights in patients with facial nerve palsy. Otol Neurotol 2001;22: Misra A, Grover R, Withey S, Grobbelaar AO, Harrison DH. Reducing postoperative morbidity after the insertion of gold weights to treat lagophthalmos. Ann Plast Surg 2000; 45: Pickford MA, Scamp T, Harrison DH. Morbidity after gold weight insertion into the upper eyelid in facial palsy. Br J Plast Surg 1992;45: Chepeha DB, Yoo J, Birt C, et al. Prospective evaluation of eyelid function with gold weight implant and lower eyelid shortening for facial paralysis. Arch Otolaryngol Head Neck Surg 2001;127: Bair RL, Harris GJ, Lyon DB, Komorowski RA. Noninfectious inflammatory response to gold weight eyelid implants. Ophthal Plast Reconstr Surg 1995;11: Seiff SR, Sullivan JH, Freeman N, Ahn J. Pretarsal fixation of gold weights in facial nerve palsy. Ophthal Plast Reconstr Surg 1989;5: Canady JW, Meine J, Thompson SA, Yuh WTC. Effects of magnetic resonance imaging fields on gold eyelid loads. Ann Plast Surg 1993;31: Lisman RD, Smith B, Baker D, Arthurs B. Efficacy of surgical treatment for paralytic ectropion. Ophthalmology 1987;94: Hofmann RJ. Treatment of Frey s syndrome (gustatory sweating) and crocodile tears (gustatory epiphora) with purified botulinum toxin. Ophthal Plast Reconstr Surg 2000;16: Lee OS. An operation for the correction of everted lacrimal puncta. Am J Ophthalmol 1951;34: Hontanilla B. Weight measurement of upper eyelid gold implants for lagophthalmos in facial paralysis. Plast Reconstr Surg 2001;108: