Secondary eyelid weight surgery in patients with facial paralysis

Introduction: Paralytic lagophthalmos in the setting of facial paralysis results in exposure keratopathy and places patients at risk for corneal injury and long term sequalae. Upper eyelid weight implantation restores passive eyelid closure and increases protection of the cornea. While effective, some patients ultimately require secondary surgery. The factors associated with eyelid weight revision remain incompletely characterized. This study identifies clinical and surgical factors associated with secondary eyelid weight surgery (replacement or removal) among patients with facial paralysis at a tertiary academic medical center. Methods: A retrospective chart review was conducted of patients who underwent eyelid weight placement for incomplete eye closure secondary to unilateral facial paralysis between January 1, 2014 and December 31, 2023. Data collected included demographics, etiology of paralysis, history of radiation therapy, paralysis severity and recovery, implant characteristics, and adjunctive facial reanimation procedures. Statistical analyses compared patient and procedural factors associated with receiving secondary or revision surgery, and among secondary cases, between those who underwent replacement versus removal. Results: Ninety-four patients met inclusion criteria, and 21 (22.3%) underwent secondary surgery. The most common indication for revision was recovery of facial nerve function (33.3%), followed by bothersome symptoms (28.6%), extrusion (23.8%), and incomplete eye closure (14.3%). Patients with partial or complete recovery of paralysis were significantly more likely to undergo secondary surgery compared to those without recovery (61.8% vs 22%; p < 0.001). A history of head and neck radiation was not significantly associated with revision (p = 0.4). There were no significant differences found with respect to age, gender, severity of paralysis, etiology, type or material of implant, or procedural setting. Conclusion: Secondary eyelid weight surgery was primarily associated with recovery of facial function followed by persistent ocular symptoms and extrusion.