'Are dynamic procedures superior to static in treating the paralytic eyelid in facial paralysis?'

Facial nerve weakness can cause deficient eye closure with reduced corneal protection. Surgical remedies can be static to oppose the levator muscle (lid loading) or dynamic procedures, which act to increase the strength of closure. This retrospective cohort study compares these groups. The hypothesis is that dynamic reconstruction has advantages over static techniques in terms of eye closure, symptomatic improvement, blink restoration, and complication rate.

Two cohorts were compared: those treated with a gold weight insertion into the upper eyelid and those who had received dynamic reconstruction. These included temporalis transfer; cross face nerve grafting alone (CFNG) and CFNG followed by free tissue transfer. Assessments included standard photography and video; measurement of eyelid excursion including residual gap and if full eye closure was possible. The presence of the blink reflex and symptoms of dry eye was assessed.

Overall improvement in eye closure was similar with the gold weight compared to dynamic procedures (5.1 mm vs 5.3 mm). Dynamic procedures however gave improved results in terms of symptom relief and restoration of blink. They also had fewer complications and revision rates overall.

The study confirms the hypothesis that dynamic reconstructions of the paralysed eyelid confer advantages compared to simple lid loading techniques. Improvements in lid excursion are similar, but symptom improvement and blink restoration are significantly better. A decision regarding eyelid reanimation should be made early in the patient's journey of facial reanimation to allow for accurate planning and placement of nerve grafts at an early stage.