Summary
When the facial nerve is weak, the eye on that side cannot close fully and the lower eyelid sags. The cornea dries out, the eye runs constantly, and over time the surface of the eye can be permanently damaged. There are several effective surgical procedures, chosen to suit the cause, severity and likelihood of recovery.
Who is this for?
I commonly see patients with:
- Bell’s palsy with persistent (>3 months) eye closure problems,
- acoustic neuroma patients before or after vestibular schwannoma surgery,
- parotid surgery with facial nerve sacrifice,
- post-traumatic facial nerve injury,
- congenital facial nerve weakness.
Urgent assessment is offered for any patient with corneal exposure or visual symptoms.
What the procedure involves
Treatment is layered. Common procedures include:
- Lubrication & taping protocols: first-line for everyone.
- Upper-eyelid weight (gold or platinum chain): implanted under local anaesthetic to help the upper lid close passively under gravity.
- Lower-lid tightening (lateral tarsal strip): a 30-minute procedure to support a sagging lower eyelid.
- Botulinum toxin to the upper-lid retractor muscle: for temporary protection while awaiting recovery.
- Brow lift for the dropped eyebrow.
- Tarsorrhaphy: joining part of the upper and lower lid for severe cases.
These procedures can be combined and staged, and may be planned alongside plastic surgery colleagues for static slings or dynamic facial reanimation.
Recovery and what to expect
- Eyelid weight surgery: bruising and swelling for 1–2 weeks; sutures removed at a week.
- Lower-lid tightening: similar 1–2 week recovery.
- Most patients notice a marked improvement in eye comfort within days.
Risks and alternatives
Risks depend on the procedure but include extrusion or migration of the eyelid weight, asymmetry, recurrence of lid laxity and (rarely) infection requiring removal. Long-term results are excellent with a well-planned, individualised approach.