Surgical Success in Facial Paralysis: A Combined Surgical Approach with Eyelid Gold Weight Implant and Tensor Fascia Lata Sling

University Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, Ss. Cyril and Methodius University, Skopje, North Macedonia

*Corresponding Author: Dr. Smilja Tudzarova-Gjorgova MD, PHD, University Clinic for Plastic and Reconstructive Surgery, Mother Teresa No.17, 1000 Skopje, Republic North Macedonia, E-mails: [email protected]; [email protected]

Received Date: January 15, 2025

Published Date: June 06, 2025

Citation: Tudzarova-Gjorgova S, et al. (2025). Surgical Success in Facial Paralysis: A Combined Surgical Approach with Eyelid Gold Weight Implant and Tensor Fascia Lata Sling. Mathews J Case Rep. 10(3):208.

Copyrights: Tudzarova-Gjorgova S, et al. © (2025).

ABSTRACT

Facial paralysis is the inability to move the muscles on one or both sides of the face due to nerve damage. Possible causes include inflammation, trauma, stroke, tumors, and this condition can be temporary or permanent. We present a case of a 45-year-old patient with post-operative facial palsy with a severe disfunction (grade 5 on The House-Brackmann grading scale) and our combined surgical approach of a gold weight insertion and a tensor fascia lata sling for lip angle suspension. This strategy proved successful, as it lessened the patient’s symptoms and it achieved a functional, as well as aesthetically pleasing result.

Keywords: Facial Paralysis, Gold Implant, Tensor Fascia Lata, n.facialis, TFL Sling.

INTRODUCTION

The normal function of a person’s facial nerve is imperative for their physical, emotional and psychological wellbeing and social functioning. Facial palsy is a condition that results from damage to the facial nerve which innervates the muscles of facial expression. It is typically idiopathic, but can also cause by infection, trauma, tumors or stroke.

According to a study by Hohman MH, Hadlock TA [1]: 61% of 1989 patients with facial palsy recorded during a 10-year period were female, and the mean age at presentation was 44.5 years (±18.6 years).

The clinical presentation includes facial weakness or paralysis and ptosis, loss of facial expression and facial asymmetry, also lagophtalmos and sialorrhea [2]. Therefore, facial nerve paralysis can and does have significant consequences. In this case report, we want to exemplify our surgical approach and highlight the pivotal role the surgeon plays in the treatment of this affliction and in improving the patient’s quality of life.

CASE REPORT

In this case report, we present the clinical case of a 45-year-old male with left-sided facial paralysis and our surgical technique for correction of the patient’s condition. The patient was referred to our clinic in January 2024. Upon physical examination, an inability to close the left eye and move the left side of the face, as well as drooping of the left mouth corner was evident. A comprehensive history was taken - the patient complained of eyelid dryness and drooling. Eight years ago, he had been diagnosed with a neurinoma in the left pontocerebellar angle and a craniotomy with tumor extirpation was performed later that same year (December 2016). Since then and over the years, he had regular doctors’ appointments with neurologists, neurosurgeons and ophthalmologists. He had also been referred to Physical Medicine and Rehabilitation, prior to consulting us.

Our planned course of action was a combination of gold weight implant under the left eyelid and a static facial suspension using an autologous tensor fascia lata sling. During the consultations, gold weights of different sizes and weights were temporarily attached to the patient’s lid as to ensure the right size and most natural eyelid closure. The final golden plate weighed 1,2 grams.

The surgery was performed in a supine position under general anesthesia. First, topical anesthesia was given, and the cornea was protected with a lid guard. Next, the incision line in the crease of the left upper palpebra was marked 8 mm from the lid margin, and then with a scalpel, an incision long 1,5 cm was made. The incision was deepened up to the tarsal plate using surgical scissors, a recessus was carefully hollowed out. The golden weight was carefully positioned at the junction of the medial third and lateral two thirds of the upper lid under the orbicularis muscle and over the tarsus, and sutured with 6/0 Polypropylene to the tarsus. The incision was then sutured with 6/0 Novafil.

Next, a longitudinal incision approximately 8 cm long was carefully made along the lateral left thigh, the center of which was over the junction of the upper and middle one-thirds of the femoral region. The incision was then carried down to the iliotibial band of the fascia lata, and the overlying fat was dissected off of the fascia bluntly. A medial longitudinal incision in the fascia was made, followed by the lateral longitudinal incision which defined the width of the graft. A distal transverse incision through the fascia followed, and it was gently elevated off of the underlying muscle. Finally, the proximal transverse incision was made, and a graft with a length of around 12 cm was acquired. The wound was then closed in two layers, using 3-0 Polyglactin 910 and 4-0 Novafil sutures, and a passive drain was placed.

Figure 1. Placement of golden weight.

Figure 2. Harvesting tensor fascia lata graft.

Then, an incision approximately 4 cm in length was made in the left temporal region, concealed by the hairline, and subsequent subdermal dissection was performed in the plane above the SMAS. The dissection ended about 1 cm above and laterally and 1 cm below and laterally to the left oral commissure. The distal end of the fascia was then cut lengthwise in the middle and separated into two strips. The fascia was placed through the tunnel elevated previously in the subdermal plane, and the two strips on the lateral end were sutured to the m.orbicularis oris and fixed at the two aforementioned points with 4/0 Polypropylene. Finally, the fascia lata was tunneled through the buccal fat pad and passed beneath the zygomatic arch to the temporal region, and stretched to the desired tension. There, the graft was fixed to the temporalis muscle with 4/0 Polypropylene. The skin was then sutured in a simple interrupted fashion using 5/0 Polypropylene.

Figure 3. Positioning tensor fascia lata graft.

After the procedure, the patient stayed in the hospital for three days during which he received intravenous antibiotics (2 grams of Ceftriaxone once a day), analgesics, gastroprotective, anticoagulant and fluid therapy.

Figure 4. Third day post-op.

Subsequently, on the third day, the patient had a dressing change and was discharged from the hospital - he was prescribed antibiotics and analgesics, as well as corticosteroids (Urbason and Dexason) and tranexamic acid. The patient was instructed he could resume his usual activities on day five after the operation.

Postoperatively, the patient had no complications in terms of hematoma, bleeding or infection. The surgical outcome was successful in providing relief of dry eye symptoms, enhanced protection of the eyes and greatly improved eyelid closure (Fig. 5e). The patient’s lip was more symmetrical with the mouth either opened (Figure 5e) or closed (Figure 5f), and the drooling was resolved. The operative scars were inconspicuous, and his left thigh showed minimal donor-site morbidity.

Figure 5. [Top row] Pre-op (a) Relaxed, (b) Eyes closed, (c) Smiling; [Bottom row] 4 months Post-op (d) Relaxed, (e) Eyes closed, (f) Smiling.

We will continue to monitor this patient to assess for any changes in the following period.

DISCUSSION

Facial paralysis poses both functional and aesthetic challenges, often caused by trauma, tumors, infections, or conditions like Bell’s palsy. Surgical intervention becomes necessary when conservative treatments, such as medications and physical therapy, fail to provide adequate results.

In the case of our patient’s facial palsy, the cause is post-operative, given that he had undergone a surgical removal of a neurinoma in the left ponto-cerebral angle 8 years ago, leading to both functional deficits and aesthetic concerns, particularly with facial expressions, drooling and eyelid closure.

The gold standard for grading facial nerve function is the House Brackmann Facial Nerve Grading System (Table 1), by which our patient is graded 5 – severe dysfunction.

Table 1. The House-Brackmann Grading Scale

Additionally, the gold weight implant was used to address the patient’s incomplete eyelid closure and the associated symptoms. This method was first described by K.Illig in 1958 [4]. Since then, both the implants and the surgical techniques have been continuously refined [5-7].

The standard weights are crafted from 99.99% gold and are precisely rounded to perfectly align with the curvature of the upper eyelid. Gold weights have many advantages: they are very well tolerated because gold is a biologically inert material that doesn’t affect MRI, and if necessary, they can be easily extracted without visible scarring.

The gold weights allow for complete eye closure in most cases, reducing the severity of corneal inflammation or ulceration, without limiting the field of vision. An ideal weight enables the patient to open and close their eyes without inducing eyelid ptosis.

While both TFL grafting and gold weight implants are effective, they come with certain challenges. TFL grafting involves careful positioning and attachment to the facial muscles, often requiring slight overcorrection to compensate for muscle relaxation after surgery. In this case, overcorrection was applied to the oral commissure to ensure optimal facial symmetry. The placement of the gold weight implant also requires precise surgical technique to ensure proper eyelid closure without impairing eyelid movement.

The success of these procedures relies on early intervention, detailed surgical planning, and thorough post-operative rehabilitation. The patient in this case showed significant improvements in both facial symmetry and eyelid function, highlighting the potential of these interventions to restore both aesthetics and function.

CONCLUSION

In conclusion, surgical techniques like TFL grafting and gold weight implants offer significant benefits for patients with facial paralysis, particularly those with prolonged or traumatic paralysis. In this case, the combined approach of gold weight implantation and lip angle suspension notably improved the patient's quality of life. The patient regained the ability to close the left eye, alleviating symptoms of dryness and irritation, and the suspension of the lip angle reduced drooling, while also giving the patient a softer facial appearance. The patient expressed high satisfaction with the results. Continued research and larger studies will help refine these surgical techniques, ensuring improved outcomes for patients in the future.

ACKNOWLEDGEMENTS

None.

CONFLICT OF INTEREST

The authors declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper.

INFORMED CONSENT

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

REFERENCES

1. Hohman MH, Hadlock TA. (2014). Etiology, diagnosis, and management of facial palsy: 2000 patients at a facial nerve center. Laryngoscope. 124(7):E283-E293.
2. Mavrikakis I. (2008). Facial nerve palsy: anatomy, etiology, evaluation, and management. Orbit. 27(6):466-474.
3. Sansone V, Boynton J, Palenski C. (1997). Use of gold weights to correct lagophthalmos in neuromuscular disease. Neurology. 48(6):1500-1503.
4. Illig KM. (1958). Eine neue Operationsmethode gegen Lagophthalmus. Klin Monatsbl Augenheilkd. 32:410-411.
5. Smellie GD. (1966). Restoration of the blinking reflex in facial palsy by a simple lid-load operation. Brit J Plast Surg. 19:279-283.
6. Seiff SR, Sullivan JH, Freeman LN, Ahn J. (1989). Pretarsal fixation of gold weights in facial nerve palsy. Ophthalmic Plast Reconstr Surg. 5(2):104-109.
7. Schrom T, Habermann K, Wernecke K, Scherer H. (2005). Implantation von Lidgewichten zur Therapie des Lagophthalmus. Ophthalmologe. 102:1186–1192.