Facial Symmetry & Eye Protection

Facial paralysis affects more than just the smile. The brow droops, the eye cannot close properly, and the face develops progressive asymmetry over time. These changes are not only cosmetically distressing — incomplete eye closure can lead to corneal damage and vision loss.¹ Dr. Lakhiani addresses these issues with a combination of targeted procedures that restore symmetry and protect ocular function.

Overview

When the facial nerve is damaged, every zone of the face is affected. While much attention is rightly paid to the smile, the upper face and periorbital region suffer equally significant consequences. Paralytic brow ptosis obstructs the visual field. Lagophthalmos — the inability to fully close the eyelid — exposes the cornea to dryness, breakdown, and permanent scarring.^1,2 The lower eyelid sags away from the eye, causing tearing and further exposure. Over months and years, the paralyzed side of the face undergoes progressive soft tissue descent, deepening the asymmetry.

Dr. Lakhiani evaluates every zone of the face systematically — brow, eye, midface, smile, and lower face — and develops a comprehensive treatment plan that addresses all of these problems, not just the one that is most visible.

Brow Lift

Paralytic brow ptosis causes the eyebrow on the affected side to droop below its natural position, creating asymmetry that can be immediately apparent and sometimes obstructing the superior visual field. Because the frontalis muscle — which normally holds the brow up — is paralyzed, the brow descends progressively without treatment.

Brow lift for facial paralysis is tailored to the patient's anatomy, the degree of ptosis, and whether other periorbital procedures are being performed simultaneously:

• Direct brow lift: An ellipse of skin is excised just above the eyebrow, elevating it to a symmetric position. This technique offers precise control over brow height and shape and is particularly reliable in patients with significant ptosis. Technical refinements — including careful scar planning and subcutaneous dissection — minimize visible scarring.³
• Endoscopic brow lift: Performed through small incisions at the hairline using an endoscope, this approach avoids direct scarring above the brow and is well-suited to younger patients or those with lower hairlines.⁴
• Internal browpexy: A suture-based suspension of the brow from within, often performed in conjunction with upper eyelid surgery, for patients with mild to moderate ptosis.
• Dual-plane lift-and-hold technique: A combination of hairline skin excision and fascia lata suspension that achieves stable, long-term brow elevation without direct scarring over the eyebrow.⁵

An important consideration when planning brow lift in facial paralysis patients is that elevating the brow can worsen eyelid closure by increasing the distance the lid must travel to close.⁶ Dr. Lakhiani carefully evaluates eyelid closure function before selecting the degree of brow elevation, and coordinates brow lift with eyelid procedures to ensure that improving one does not compromise the other.

Eyelid Procedures

Eyelid dysfunction in facial paralysis involves three distinct anatomical problems, each with its own surgical solution. Most patients require more than one of these interventions, and they are commonly performed together.

Upper Eyelid Weight (Platinum or Gold)

When the orbicularis oculi muscle is paralyzed, the upper eyelid cannot close fully. This condition — lagophthalmos — leaves the cornea exposed during blinking and sleep, leading to dryness, exposure keratopathy, corneal ulceration, and, if untreated, permanent vision loss.^1,2

The standard surgical solution is implantation of a small platinum or gold weight in the upper eyelid. Gravity assists the weighted lid in closing during blinking and spontaneous eye closure, while the levator muscle — which is unaffected by facial nerve paralysis — continues to open the eye normally. Key features of this procedure include:

• Weight selection is customized: the size is chosen preoperatively using external trial weights to achieve complete closure without excessive ptosis
• Postseptal placement (behind the orbital septum rather than in the pretarsal plane) reduces visibility, migration, and extrusion while maintaining efficacy — with complete or near-complete closure achieved in up to 98% of patients⁷
• A systematic review of 1,205 patients found complete or near-complete eyelid closure in 83–92% of cases, with high patient satisfaction averaging 7.9 out of 10²
• The procedure can be performed under local anesthesia with relatively straightforward recovery
• Platinum weights are preferred by many surgeons as they are MRI-compatible and somewhat less visible than gold due to their higher density (allowing a smaller, thinner implant)
• The implant is reversible if facial nerve function recovers

Early eyelid weight placement in patients with lagophthalmos has been shown not only to protect the cornea but may also support improved facial recovery and reduce the development of synkinesis.⁸

Paralytic Ectropion Repair

Lower eyelid paralysis causes the lid to lose its muscular support and sag away from the globe — a condition called paralytic ectropion. The eyelid margin falls outward, the punctum (tear drainage opening) is displaced away from the eye, and tears pool and spill (epiphora). The exposed lower conjunctiva and sclera become irritated and vulnerable to infection.

Surgical repair of paralytic ectropion focuses on restoring the lower eyelid to its natural position against the globe by tightening the lateral canthal tendon and supporting the lower lid horizontally:

• Lateral tarsal strip procedure: The standard approach — the lower lid is divided, the tarsal strip is prepared and shortened, and it is secured to the periosteum of the inner aspect of the lateral orbital rim to shorten and elevate the lower eyelid⁹
• Canthoplasty: A broader category of procedures that reconstruct or reattach the lateral canthal tendon to the orbital rim
• Canthopexy: A suture-based tightening of the existing canthal tendon without formal takedown, suitable for milder laxity
• Ectropion repair is often combined with midface or subperiosteal lift procedures that provide additional support to the lower lid by restoring midface volume and position¹⁰

The choice of technique depends on the degree of laxity, the position of the lower lid, and whether midface support procedures are being performed simultaneously.

Ptosis Correction

Upper eyelid ptosis (drooping of the lid itself) may occur in the context of facial paralysis from associated nerve involvement — including involvement of branches of the oculomotor nerve — or from compounding conditions. This is distinct from lagophthalmos (failure to close) and brow ptosis (drooping of the brow).

Surgical correction depends on the degree of ptosis and the amount of residual levator muscle function:

• Levator advancement: The levator palpebrae superioris muscle and its aponeurosis are advanced and reattached to the tarsal plate, appropriate when some levator function is preserved
• Frontalis sling: When levator function is absent or severely reduced, a sling of fascia lata or synthetic material is used to connect the eyelid to the frontalis muscle, allowing the patient to raise the lid by raising their eyebrow

Ptosis correction is planned carefully in facial paralysis patients, as aggressive elevation of the upper lid may worsen corneal exposure if lagophthalmos is also present.

Rhytidectomy (Facelift) for Symmetry

In longstanding facial paralysis, the paralyzed side of the face undergoes progressive structural change. Without the tonic activity of the mimetic muscles, soft tissues descend: the midface drops, the nasolabial fold deepens, jowls form, and the facial outline becomes increasingly asymmetric compared to the animated opposite side. This is not a cosmetic aging change — it is a structural consequence of prolonged denervation.

A targeted rhytidectomy (facelift) on the affected side directly addresses this asymmetry. The goal is not rejuvenation — it is to restore balance between the two sides of the face at rest. Key principles include:

• The procedure is performed on the paralyzed side only, or predominantly so, to match the resting appearance of the unaffected side
• SMAS (superficial musculoaponeurotic system) repositioning addresses the underlying structural descent, not just redundant skin
• Fat grafting is commonly combined to address volume asymmetry in the cheek and perioral region
• Rhytidectomy for facial paralysis is supported by evidence demonstrating substantial improvements in facial symmetry, patient satisfaction, and quality-of-life outcomes¹¹
• The procedure is most commonly performed as a secondary or adjunctive procedure, timed alongside or after dynamic reanimation (smile reconstruction), so that the effects of dynamic procedures can be assessed before finalizing the static symmetry plan

When combined with dynamic reanimation — nerve transfer or free functional muscle transfer — rhytidectomy completes the symmetry picture: the dynamic procedure restores movement, and the rhytidectomy corrects the structural asymmetry that movement alone cannot fully address.

When to Consider These Procedures

The timing and urgency of symmetry and eye protection procedures depends on the specific problem:

• Immediate (acute paralysis): Patients with new-onset lagophthalmos need corneal protection urgently. Eyelid weight implantation can be performed early — even within weeks of paralysis onset — and may be removed if nerve function recovers. Lubricating eye drops, ointment, and protective eyewear are instituted immediately while surgical planning proceeds.
• Early (first year): Brow lift and ectropion repair are commonly performed within the first year of paralysis, particularly when brow ptosis is obstructing vision or when lower lid laxity is causing significant symptoms.
• Late (longstanding paralysis): Rhytidectomy and volume symmetry procedures are typically performed after dynamic reanimation procedures have been completed — or in patients who are not candidates for dynamic reanimation — addressing the cumulative structural asymmetry that develops over time.
• Patients undergoing smile reconstruction who also need symmetry optimization benefit from a coordinated plan in which dynamic and static procedures are staged logically.

Dr. Lakhiani's Approach

Dr. Lakhiani evaluates every patient with facial paralysis systematically across all zones of the face: brow, eye, midface, smile, and lower face. Many surgeons focus exclusively on the smile. Dr. Lakhiani's approach recognizes that meaningful improvement in a patient's appearance and quality of life requires addressing every zone that is affected.

For periorbital and symmetry procedures, this means:

• Comprehensive assessment of lagophthalmos, Bell's phenomenon, corneal sensitivity, and existing corneal changes at every visit
• Close coordination with ophthalmology for patients with significant corneal exposure
• Weighing the interaction between procedures — particularly the relationship between brow elevation and eyelid closure — before finalizing a surgical plan
• Planning staged or simultaneous procedures depending on the patient's functional needs and priorities
• Coordination through the Facial Nerve Clinic, co-directed with Dr. Dayan, where patients receive comprehensive multidisciplinary evaluation and a unified treatment plan