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Facial paralysis — facial palsy

Facial palsy is paralysis of part of the face caused by non-functioning of the facial nerve that controls the muscles, especially around the eye and to the mouth. The facial nerve is also called the seventh cranial nerve.
It has a complex course from the brain stem to reach the muscles governing facial expression. It controls the muscles that lift the eyebrows, the muscles that close the eyelids, the muscles of the cheek and around the mouth.
Facial palsy can be congenital — present at birth or shortly after — or acquired, possibly following a viral illness or through no obvious cause. Under these circumstances, it is referred to as Bell's palsy. Sometimes a tumour can compress and damage the nerve. Other causes include serious infections and skull fracture.
Facial paralysis usually affects half the face, which flattens and loses forehead wrinkles and horizontal lines. There is also a droopy eyebrow, difficulty closing the eye, an inability to whistle and the corner of the mouth is pulled down.
The effects on the eyes are particularly significant. The upper eyelid can be a little too high and the lower eyelid can sag and turn outward (ectropion), resulting in a watering eye, inability to close the eye and exposure or drying of the cornea. The eye can become red, vision can blur and sight is occasionally affected by ulceration and scarring (exposure keratopathy).

Facial Nerve insults can be considered as "Pre-Stapedial" or "Post-Stapedial" depending on whether they occur before the facial nerve divides and sends branches to the ear drum ("Nerve to Stapedius"). Pre-stapedial insults have the potential to involve the lacrimal nerve and cause even more dryness of the eye.

More unusual problems include losing the use of the nerve (the trigeminal, or fifth cranial, nerve) that controls sensation in the eye. This usually happens in "pre-stapedial" insults as a result of surgery on a large, benign brain tumour (an acoustic neuroma), which has affected both the facial nerve to the muscles and the sensory nerve to the front of the eye
Rarely, patients may suffer a lack of sensation on the surface of the eye (cornea), so that they cannot feel dryness, foreign bodies or injuries to the surface of the eye. This puts them at risk of developing a corneal ulcer and suffering severe damage to their sight.
Crocodile tears are another rare consequence of facial nerve paralysis. They occur when the damaged nerve tries to grow back along its old pathway but goes instead to the tear (lacrimal) gland and to the muscles of the jaw. This results in embarrassing tears when the patients chews. Again, this can occur following "pre-stapedial" facial nerve insults.

Other consequences of a nerve regrowing in the wrong direction include closing of the eyelid and muscle spasms in the eyelid, cheek and around the mouth.

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Eye care for facial nerve weakness


Assessing eye health

Traditionally facial palsy has been graded as being mild, moderate or severe depending on how much the eyelids are able to close on blinking. If most of the eye is covered then the palsy is mild. If some of the eye can be covered on forced blinking, then the palsy is moderate. If the eyelids can cover none of the front of the eye during forced blinking, then the palsy is graded as being severe. The Sunnybrook facial grading system is a well-established tool for assessing facial movement outcomes but is not necessarily the best for eyes.

Mr Malhotra has developed the CADS grading score specifically for ophthalmic grading of facial nerve weakness. CADS stands for Cornea (for risk of damage), Asymmetry, Dynamic function and Synkinesis. . The higher the number the more severe. Each patient is then graded C1A2D2S0 etc. or C2aA2D2S0 etc. 


Initial treatment for corneal exposure

Frequent instillation of artificial tear drops in the day time (at least every 2 hours) and lubricant ointment (e.g. Lacrilube) at night time.

If drops are needed more than 4 times a day then they should be PRESERVATIVE-FREE drops. Preservatives used in large quantities or over a prolonged period of time may damage the delicate cells on the surface of the eye or cause inflammation.

Ointment can be used in the day time also, but this does cause a lot of blurring of the vision. 

Specific groups/types of lubricants include:

• Carmellose
– Celluvisc, Optive

• Sodium Hyaluronate
– Hylotears, Hyalbak 0.15%

• Others, ie lipid polymers
– Ie Systane, Optive plus

• Disacharide
– Trehalose (Thealoz)

• Carboxy methyl cellulose
– Hypromellose BP, Tears naturale

• Polyvinyl alcohol
– Liquifilm, Sno Tears, Hypotears

• Aqueous carbomer gels
– Viscotears, Artelac, Geltears

• Paraffin ointments
– Lacri-lube, simple eye ointment, xailin ointment (new and preservative-free)

If the eye does not close at night time, it can be taped shut. This can be difficult to do if the eyelid skin is greasy from ointment application. Cutting and applying cling film around the bones surrounding the eye creates a ‘moist chamber’ when sleeping. This helps to prevent the drying of the eye at night, and adds a little protection against damage caused by rubbing of the eye against the sheets or pillow. Consider a padded/cushioned night mask to help push the eyelid closed at night.

A temporary external weight may be applied to the eyelid skin to aid blink-closure in the day. Mr Malhotra recommends temporary external eyelid weights such as blinkese external weights available from Veni Vidi UK Tel. +44 (0)1422 254064.

As an alternative to the double-sided tape supplied with external weights, Mr Malhotra recommends a water-based MEDICAL GLUE to maintain retention of the external weight to the eyelid skin, for example Pro-Bond G609 from Technovent

blinkeze external lid weights
Mr Malhotra advises glasses with visors or wraparounds for anyone with facial nerve weakness and incomplete eyelid closure. Here is a link for a good example of moisture chamber glasses.

Mr Malhotra also advises the use of air humidifiers at home and in the work-place.

It is very important to stretch both upper and lower eyelid skin early on after facial palsy as the skin may contract with time.

It is also important to improve eyelid margin meibomian gland dysfunction by carrying out daily hot compresses. Mr Malhotra recommends the Eyebag Company Mask. Use this daily, perhaps in the evening or before bedtime.

It can be helpful to sleep with a contoured night mask at night during sleep in order to avoid having to tape your eyelids shut.

Punctal Plugs may not to be considered where the lower eyelid is drooping away from the eyeball but otherwisen can increase the wetting and comfort of the eye by allowing fewer tears or drops to drain away into the nose. If lacrimal nerve is involved and eye is very dry then punctal plugs or permanent punctal occlusion is very helpful. 

It is helpful to put a "blinker reminder" on your computer to remind you to blink! For a more sophisticated tool that will help you in the long-term to develop better blinking habits (and better computer habits overall), try WorkRave.

Surgical treatment

Corneal exposure can be treated surgically if conservative measures fail.
Aims of surgery of the eyelids are to: 
  • Increase the wetting of the cornea
  • Improve the position of the lower eyelid which maybe lax
  • Restore natural symmetry of shape, height and volume the lower eyelid-cheek region
  • Restore natural symmtery of shape, height and volume of the brow-temple region

When to consider? 

As long as there is no damage to the eye from exposure, many doctors advisable for the patient to wait 3 months before embarking on significant eyelid surgery to allow spontaneous recovery of the facial nerve. Mr Malhotra will advocate surgery at 3 months and often before but emphasises the importance of it being minimally invasive, i.e. suture-sling techniques.
Treatment is often in a staged approach. This is very useful as those with mild palsies require less complicated procedures and those with more severe palsies may require a greater number and complexity of eyelid operations. 
Most patients with a permanent palsy will require additional help with eyelid closure in the form of eyelid surgery. The aims of surgery are to protect the front of the eye, to improve the function and position of the eyelids, improve cosmesis and reduce asymmetry between the two sides. However, as this is a lifelong problem, patients with a facial palsy may need multiple eyelid operations over time.
It’s important to remember to never remove skin in a patient with facial palsy (except in a brow lift). Mr Malhotra strongly advocates this philosophy.
Mr Malhotra advocates lower eyelid "suture-sling" techniques in order to maintain a natural lower eyelid appearance with minimally-invasive surgery. This may need repeating within a few years but is usually performed under local anaesthesia. In selected cases he may use a patient's own tissue (eg fascia lata).

He also advocates recession of the eyelid retractors in order to elevate the lower eyelid and reduce upper eyelid retraction and improve eyelid closure. 
Upper eyelid lowering – for improved closure
  • Weaken the levator muscle that lifts the eyelid
  • Narrows the vertical opening of the eyelids
  • Can be repeated if further lowering of the upper lid is required. 
  • Reversible in case there is recovery of the facial palsy. 
  • Often used in combination with other eyelid operations 
  • Upper eyelid lowering – to reinstate blink and for improved closure
Mr Malhotra strongly advocates upper eyelid loading with weights in order to improve eyelid blink and closure. This was traditionally with the use of gold weights, however is nowadays carried out with platinum chains. The weight allows the eyelid to blink.

Lagophthalmos is not just on gentle and forced closure, it is during blink as well and this is something ignored traditionally by doctors when assessing the ability of the eyelids to close. Benefits include: can improve cosmetic appearance, improved protection of the cornea, reduced pain caused by dry eye. Problems include: poorly placed or bulky weight may be less aesthetically pleasing, the weight may be rejected by the eyelid, astigmatism risks.

Placing of the weight can alter success rates, some surgeons advocate it is important not to place the weight in a pre-tarsal location as it has a prominent appearance and can easily extrude, but to use a high-tarsal technique instead. Mr Malhotra places implants above the tarsal plate so that they are not visible or prominent with the eye open or closed. The Malhotra platinum segments chain is becoming more popular due to their potential for adjustability. 

Drooping of the brow

Can be improved by excising some of the forehead skin above the eyebrow (via a cut in the skin just above the eyebrow hairs). 
Over time the brow may drop again due to the effect of lack of tone in the forehead muscle and the effect of gravity. In younger individuals, a brow-lift can be carried out endoscipically with incisions at or behind the hairline.

Fat transfers

Fat transfers in the eyelid region restore volume to the eyelid region and improve eyelid support as well as aesthetic symmetry. This is something that is carried out in a few centres for selected cases. It is a procedure that is available in specialist units where volume loss around the eyes are recognised as contributing to eyelid closure limitation or asymmetry. Mr Malhotra performs fat transfer for the indication of facial nerve weakness for volume-related lower eyelid-cheek support and symmetry and to restore symmetry and lift of the eyebrow region.

Right facial palsy - Before surgery (Greater than 6 months since onset of palsy)

After surgery. The patient underwent insertion of right upper eyelid Malhotra Platinum Segment chain, levator recession and lower eyelid transcaruncular medial canthal tendon plication, suture sling and lower retractor recession. Three months later, he underwent right direct browlift. The patient has also received active facial therapy and botulinum toxin therapy for better symmetry.
Right facial palsy after surgery


Occasionally, the front of the eye (cornea) becomes ulcerated and very painful, or the eye becomes red. This condition is known as exposure keratopathy with severe keratitis. Lubricants and other eye drops may not be enough to improve this condition, so it can be necessary to lower the upper eyelid temporarily.

This is done by giving a small injection of Botox underneath the upper eyelid, which temporarily paralyses the muscle that lifts the eyelid open and allows the eyelid to drop over the eye (protective ptosis) so that the keratitis or ulcer can heal. These injections can last up to three months and be repeated. Alternatively, surgery may be needed.

Botox can also be injected into the tear (lacrimal) gland to prevent crocodile tears and to deal with tics caused by the facial nerve regrowing in the wrong direction.

All procedures begin with a consultation. For full information about what to do before and after surgery, see Patient information – care plan for eyelid or orbital surgery.


Mr Malhotra and facial palsy

Mr Malhotra is a member of the Queen Victoria Hospital Facial Palsy multi-disciplinary team and a member of the medical advisory board of the Facial Palsy UK charity.
Mr Malhotra has developed:
  • The transcaruncular medial canthal tendon lower eyelid suture sling technique
  • The Malhotra Platinum segment customised platinum chain
  • The CADS facial weakness ophthalmic grading scale

Publications by Mr Malhotra related to facial nerve palsy include:

Bell’s facial nerve palsy in pregnancy: a clinical review A Hussain, C Nduka, P Moth, R Malhotra J

Periorbital Autologous Fat Grafting in Facial Nerve Palsy. WF Siah, AS Litwin, C Nduka, R Malhotra. Ophthal Plast Reconstr Surg. 2017;33(3):202-208.

Late outcomes of gold weights and platinum chains for upper eyelid loading. WF Siah, S Nagendran, Petrina Tan, SMA Ahmad, AS Litwin, R Malhotra. Br J Ophthalmol. 2018 Feb;102(2):164-168.

Outcomes of lower-eyelid retractor recession and lateral horn lysis in lower eyelid elevation for facial nerve palsy P Tan, J Wong, WF Siah, R Malhotra Eye (Lond). 2018 Feb;32(2):338-344.

Paradoxical Frontalis Activation: An Underrecognized Consequence of Facial Palsy. Cooper L, Izard C, Harries V, Neville C, Venables V, Malhotra R, Nduka C. Plast Reconstr Surg. 2018 Feb;141(2):263e-270e.
ObstetGynaecol. 2017 May;37(4):409-415.

CADS grading scale: towards better grading of ophthalmic involvement in facial nerve paralysis.
R Malhotra, K Ziahosseini , A Litwin, C Nduka, N El-Shammah. Br J Ophthalmol. 2015 2015.

Platinum segments: a new platinum chain for adjustable upper eyelid loading.
R Malhotra, K Ziahosseini, C Poitelea, A Litwin, S Sagili. Br J Ophthalmol. 2015

Ophthalmic grading of facial paralysis: need for a closer look

K Ziahosseini, C Nduka, R Malhotra (Accepted Br J Ophthalmol)
Transcaruncular Medial Canthal Tendon Plication with Lower Eyelid Suture Sling in Facial Nerve Palsy
M Sira, JH Norris, C Nduka, R Malhotra Orbit. 2014 Jun;33(3):159-63. 
A Comparison of Facial Muscle Squeezing versus Non-facial Muscle Squeezing on the Efficacy of BotulinumToxin-A Injections for the Treatment of Facial Dystonia
P O' Reilly, J Ross, JH Norris, R Malhotra. Orbit. 2012 Dec;31(6):400-3.
Cosmetic Comparison of Gold Weight and Platinum Chain Insertion in Primary Upper Eyelid Loading for Lagophthalmos
JC Bladen, JH Norris, R Malhotra. Ophthal Plast Reconstr Surg. 2012 May;28(3):171-5.

Indications and outcomes for revision of gold weight implants in upper eyelid loading
JC Bladen, JH Norris, R Malhotra Br J Ophthalmol. 2011 Oct 27. 
Blink-lagophthalmos and dry-eye keratopathy in non-facial palsy patients: clinical features and management with upper eyelid loading
V Patel, SM Daya, D Lake, R Malhotra Ophthalmology. 2010 Nov 18.
The lacrimal bypass tube for lacrimal pump failure due to facial palsy
SN Madge, R Malhotra, JL DeSousa, A McNab, B O’Donnell, P Dolman, D Selva American Journal of Ophthalmology, November 5, 2009
Corneal astigmatism with upper eyelid gold weight implantation using the combined high pretarsal and levator fixation technique
GM Saleh, I Mavrikakis, JL deSousa, W Xing, R Malhotra Ophthalmic Plastic and Reconstructive Surgery, September-October 2007 23(5):381-3
Techniques for upper eyelid loading with gold weights in facial palsy
I Mavrikakis, R Malhotra Ophthalmic, Plastic and Reconstructive Surgery, 2006 22(5):325-330
Facial palsy-induced blepharospasm relieved by a Bangerter foil
S Sagili, R Malhotra, J Elston Movement Disorders, September 2005 20(9):1231-2
Aberrant facial nerve regeneration: an under-recognised cause of ptosis
C Chen, R Malhotra, J Muecke, G Davis, D Selva Eye, 2004 18:159-62


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Patient responses

Dear Mr Malhotra, I just wanted to say a huge thank you to you and your team. Since my gold weight eyelid surgery I have regained a blink and my eyes are wonderful! It may not seem much to you but to me it is MASSIVE. (They have not been comfortable for over 3 years). Thank you so much to you all.

Going From Gold to Platinum

It is now 8 years since I started on my journey with facial palsy. It was in December of 2006 that my brain tumour was discovered and diagnosed originally as an acoustic neuroma. Following removal of the tumour in June 2007 via surgery the tumour was found to be a facial neuroma. As a result 1 lost the facial and acoustic nerves on the left side and had damage to vestibular nerve. I was left with facial paralysis on the left side,single sided deafness and vestibular weakness.

I was lucky enough to receive reconstructive surgery 4 months later and received a hypoglossal anastomosis and a gold weight placement in my left eyelid,together with a tarsorrraphy. With all the amazing work now completed by the surgeons,it was now up to me to work hard to get my face functioning again as best as possible.One of the benefits was immediate from day one though and that was being able to close my eye again for the first time in months, a great relief.

Initially I rested and saw out 2007 and entered 2008 requesting physiotherapy, speech therapy,CBT and investigated hearing aid possibilities. It took a long time to get all these in place.

My physiotherapy was a key part to my rehabilitation and my function gradually improved and still does to this day with 20 minutes spent on the face at least 5 days a week. It was through my physiotherapy request that I was introduced,to Charles Nduka,Vanessa Venables,Catriona Neville and later Raman Malhotra at the Queen Victoria Hospital in East Grinstead. With their help and guidance Ihave received further treatment with botox therapy and most recently underwent further  eye surgery during which I had the Gold weight changed to Platinum Segments.
The gold weight,whilst functional was quite big and very lumpy,I was often asked if I had a sting or huge sty on my eyelid and would often take to wearing sunglasses to hide it whenever possible. The weight had moved slighty creating an uneven weight balance over the lid and this was uncomfortable. The eye also appeared much more open that my normal eye.This was particularly apparent in photographs,which I avoided if at all possible.

When I was offered the chance to change from the gold weight to the platinum segments,I was over the moon. I had the surgery in April last year. Mr Malhotra spent some time on the surgery and not only implanted the new platinum segments but reversed the tarsorraphy,did a lower eyelid retractor recession,lateral horn release and a transcaruncular MCT suture sling. All above and beyond the brief but then that's what they do at QVH! Needless to say I didn't look my best afterwards but the eye healed very well over the next two months,the only problem I encountered was a little blocked duct on the lower lid but this was treated quickly and soon my eye was unrecognisable,looking far more natural and in keeping with my right eye.

The left eye feels so comfortable now and the eyelid is flat and natural looking with no lump.In fact you cannot tell I have implants in the eyelid at all. The eye closes better and the weight distributed evenly along the lid. I do my physiotherapy daily getting members of the family to tell me if its closed or not,it is getting stronger all the time. My self-esteem is much greater now,I am not
so self-conscious and no longer grab my glasses to hide behind. You never know Imay face a camera soon! ;)
Iam so gratefulto Raman Malhotra and all the team at East Grinstead for the difference they have made to my daily life and living with Facial Palsy. Being given back the function that we so often take for granted is priceless. The visual improvement helps us face the world again and not feel so conspicuous.

Thank You All So Very Much.

For more information see Facial Palsy UK.

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Benign eyelid lump — Chalazion

Benign eyelid lump — Chalazion — Patient information


Cataracts — Patient information

Drooping upper eyelids — Ptosis

Drooping upper eyelids — Ptosis — Patient information

Excessive, involuntary blinking — Blepharospasm

Excessive, involuntary blinking — Blepharospasm — Patient information

Eye bags/heavy eyelids — Blepharoplasty

Eyelid skin cancer

Eyelid skin cancer — Patient information

Facial paralysis — Facial palsy

Facial paralysis — Facial palsy — Patient information

Inward-turning eyelid — Entropion

Inward-turning eyelid — Entropion — Patient information

Outward-turning lower eyelids — Ectropion

Outward-turning lower eyelids — Ectropion — Patient information

Thyroid eye disease

Thyroid eye disease — Patient information

Watery eye — Epiphora

Watery eye — Epiphora — Patient information


Artificial eyes and orbital implants

Artificial eyes and orbital implants — Patient information

Asian eyelid surgery

Asian eyelid surgery — Patient information


Botox — Patient information

Brow lift

Brow lift — Patient information

Cataract removal and lens replacement

Chemical peel

Chemical peel — Patient information


Eyelid lift — Blepharoplasty

Eyelid lift — Blepharoplasty — Patient information


Cheek and facial contouring

Cheek and facial contouring — Patient information

Lip filling and shaping

Lip filling and shaping — Patient information

Tear trough fillers

Tear trough fillers — Patient information

Upper eyelid contouring

Upper eyelid contouring — Patient information

Mohs surgery

Mohs surgery — Patient information

Ptosis surgery


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