Gold Weight Implantation in the Upper Eyelid for Facial Reanimation

Rationale

Indications

• Complete or prolonged facial paralysis (expected >6 months) with lagophthalmos
• Exposure keratitis or corneal risk
• Patients who have undergone facial nerve sacrifice (e.g., during parotidectomy or skull base surgery)
• Often combined with other procedures: browlift, lower eyelid tarsal strip, tarsorrhaphy, or temporalis transposition - Cummings Otolaryngology, p.1520; Shambaugh Surgery of the Ear

Preoperative Weight Selection (Weight Titration)

1. A series of weights in 0.2 g increments are fixed to the upper lid externally with adhesive tape.
2. The weight is centered over the medial limbus (between the mid-pupillary line and medial limbus).
3. The patient trials the weight for at least 15 minutes, including while lying supine, to confirm:
   • Complete eye closure is achieved
   • No excessive ptosis or unnatural appearance
4. Once selected, the supratarsal crease is marked before injection.

Surgical Procedure (Step by Step)

• Performed under local anesthesia in the office or operating room setting
• 1% Lidocaine with 1:100,000 Epinephrine injected into the upper eyelid

• A 2 to 2.5 cm incision is created along the supratarsal (upper eyelid) crease, approximately 10 mm from the inferior margin of the upper lid
• Incision carried through the orbicularis oculi muscle down to the superficial surface of the tarsal plate
• The orbital septum is NOT violated

• A small sub-orbicularis pocket is dissected between the orbicularis oculi and the tarsal plate
• The pocket should extend inferiorly just above the free lid margin to prevent implant protrusion

• The weight is centered over the medial limbus
• Secured with 6-0 clear nylon sutures in 3-point fixation through all plate holes, placed partial thickness through the tarsal plate
• Sutures pass horizontally through the tarsal plate (partial thickness); the undersurface of the eyelid is inspected to ensure conjunctival integrity is maintained
• Sutures tied inferiorly (x2 bottom) and superiorly (x1 top)

• Orbicularis oculi muscle repaired with two buried interrupted 5-0 Vicryl sutures
• Skin closed with 6-0 fast-absorbing gut sutures or equivalent

Postoperative Care

• Incision cleaned BID with half-strength hydrogen peroxide
• Erythromycin ophthalmic ointment to the suture line BID
• Follow-up at 2 weeks (or 5 days for suture removal)
• Patients with platinum or gold weights can safely undergo MRI

Gold vs. Platinum Weight

Complications

• Implant migration or extrusion
• Ptosis obscuring the pupil (if weight too heavy)
• Residual lagophthalmos (if weight too light)
• Infection (rare)
• Capsule formation
• Upper eyelid contour distortion
• Entropion with trichiasis
• Corneal ulceration from persistent exposure

Place in the Broader Reanimation Algorithm

• Browlift (for brow ptosis)
• Lateral tarsorrhaphy or tarsal strip for lower eyelid ectropion
• Temporalis transposition or free muscle transfer for midface/lower face reanimation
• In cases of partial paralysis or nerve recovery, an eyelid spring can achieve a more dynamic blink (though revision rates approach 100%)

Gold Weight vs. Gold Plate - Are They the Same?

What the implant actually is

• In all major textbooks (Cummings, K.J. Lee, Scott-Brown, Shambaugh), it is consistently called a "gold weight" or "eyelid weight"
• The term "weight" is functionally accurate - the implant works purely by gravity-assisted loading to pull the eyelid down for closure
• Calling it a "plate" is descriptive of its shape, not a separate device

The implant family - there are 3 forms

Bottom line

Timing of Neural Anastomosis in Free Muscle Transfer for Facial Reanimation

Approach 1 - One-Stage Procedure (Nerve anastomosis done INTRAOPERATIVELY, same sitting)

• The free muscle (usually gracilis) is transferred and the obturator nerve of the gracilis is coapted directly to the masseteric nerve in the same operation
• Neural anastomosis is done intraoperatively - no waiting
• Movement begins within 4 to 6 months after surgery
• Provides strong, reliable muscle contraction and good oral commissure excursion
• Drawback: smile requires voluntary jaw clenching - no spontaneous/emotional smile
• Success rate ~92%
• Indications: patients >40 years old, unavailable contralateral facial nerve, patient preference for single-stage surgery with faster results

Approach 2 - Two-Stage Procedure (Nerve anastomosis done AFTER a waiting period)

• Sural nerve is harvested and tunneled across the face subcutaneously (cross-face nerve graft)
• One end is coapted to a buccal branch of the contralateral (normal) facial nerve
• The other end sits ready on the paralyzed side, marked with a suture or small tube
• No muscle transfer yet
• Axons begin to grow across the sural nerve graft at ~1 mm/day

• Axon regeneration is clinically monitored using the Tinel sign - tapping the tip of the nerve graft on the paralyzed side produces tingling on the normal side, confirming active axons have reached the end of the graft
• Intraoperative facial nerve EMG at the second stage confirms live axons

• Free gracilis muscle is transferred
• Obturator nerve of the gracilis is coapted end-to-end to the active CFNG tip at this point
• Movement begins 6 to 9 months after the muscle transfer (Stage 2)
• Advantage: produces a spontaneous, emotionally driven smile because the neural input comes from the normal contralateral facial nerve
• Success rate ~80%
• Indications: younger patients, patients who strongly desire spontaneous smile

Approach 3 - Dual Innervation (Combines both)

• A cross-face nerve graft is placed first (as in the two-stage approach), but simultaneously or at the time of muscle transfer, the masseteric nerve is also coapted to the gracilis
• Goal: combine the strength and reliability of the masseteric nerve with the spontaneity of the facial nerve input
• The masseteric nerve provides early strong contraction; the CFNG eventually adds emotional drive
• Still an evolving technique - more data needed on long-term outcomes

Summary Table

The Core Concept

Recurrent Facial Nerve Palsy

Definition

• Incidence of recurrence in patients with idiopathic Bell palsy: ~9-13%
• Of those recurrences: 38% are ipsilateral, 62% are contralateral
• Mean interval between recurrences: 9.8 years (range: 1 month to 43 years)
• Slight female predominance; association with diabetes mellitus (39% in one series)

The Critical Clinical Rule

Ipsilateral recurrence = suspect a tumour until proven otherwise

Causes of Recurrent Facial Palsy

1. Idiopathic (Recurrent Bell Palsy)

• Most common cause overall
• Patients with recurrence are 2.5x more likely to have a positive family history
• Prognosis: controversial - some authors say subsequent attacks have a poorer prognosis, others find no difference
• Recurrence constitutes a stronger indication for surgical decompression (middle cranial fossa approach) by some authors

2. Melkersson-Rosenthal Syndrome (MRS)

• Complete triad present in only 1/4 of patients - monosymptomatic or oligosymptomatic presentations are common
• Onset usually in the second decade of life
• Lip biopsy shows non-caseating epithelioid granulomas surrounded by histiocytes, plasma cells, lymphocytes
• The palsy has abrupt onset identical to Bell palsy; bilateral sequential paralysis and relapse after initial recovery are common
• Prognosis much worse than recurrent Bell palsy - only 14% recover to House-Brackmann Grade 1 by 1 year vs 71% in recurrent Bell palsy
• Treatment: steroids, metronidazole, dapsone, acyclovir, methotrexate - all without consistent response; facial nerve decompression has been reported to halt recurrences in some series
• Association with Crohn's disease and sarcoidosis should be considered

3. Neoplasms (Must Exclude)

• Parotid tumours (especially slow-growing malignancies)
• Facial nerve schwannoma
• Cholesteatoma eroding the facial canal
• Perineural spread of cutaneous malignancy
• Any ipsilateral recurrence with progressive/incomplete recovery >3-6 weeks mandates imaging

4. Infectious Causes

• Herpes simplex type 1 - recurrence is common (reactivation)
• Herpes zoster (Ramsay Hunt) - recurrence is rare
• Lyme disease
• HIV infection (at any stage)
• Tuberculosis, syphilis, leprosy

5. Systemic/Inflammatory Conditions

• Sarcoidosis (Heerfordt syndrome - uveoparotid fever with facial palsy)
• Guillain-Barré syndrome - bilateral concurrent palsy
• Multiple sclerosis (central cause)
• Leukaemic infiltration, cerebral lymphoma

6. Familial Facial Palsy

• 6-8% of Bell palsy patients have a positive family history
• Families with multiple affected members over generations are documented
• Usually early onset, recurrent, excellent prognosis

7. Other

• Osteopetrosis (narrowing of cranial foramina - recurrent palsy, deafness, optic atrophy)
• Exposure to disinfectants/toxins (e.g., chlorocresol - documented cases of >50 episodes)

Pattern of Recurrence and What It Suggests

Workup for Recurrent Facial Palsy

1. Full history - onset pattern, completeness, recovery, family history, systemic symptoms
2. Examine lips and tongue - look for orofacial edema and fissured tongue (MRS)
3. MRI with gadolinium - especially for ipsilateral recurrence (tumour, nerve enhancement)
4. High-resolution CT - bony anatomy, cholesteatoma
5. EMG/electroneuronography - extent of degeneration
6. Lip biopsy - if MRS suspected (non-caseating granulomas)
7. Serology - HSV, VZV, Borrelia, HIV, ACE level (sarcoidosis)

Management Highlights

• Ipsilateral recurrence - urgent MRI, low threshold for surgical exploration
• Melkersson-Rosenthal - treat symptomatically; consider surgical decompression if recurrences are frequent
• Bell palsy recurrence - steroids as per primary episode; decompression debated for repeat episodes
• Prognosis - progressively poorer recovery with each recurrence in MRS; similar or slightly worse in recurrent Bell palsy

Mastoid Obliteration - Indications

What is Mastoid Obliteration?

When Is It Performed?

1. Primary obliteration - done at the time of the original canal wall-down (CWD) mastoidectomy
2. Secondary (revision/rehabilitation) obliteration - done later to address a problematic pre-existing mastoid bowl

Indications

A. Primary Obliteration (at time of CWD mastoidectomy)

1. Large Mastoid Cavity

• A large, well-pneumatised mastoid creates a very large bowl after CWD surgery
• Large cavities are harder to self-clean, accumulate keratin debris, and are prone to chronic discharge
• Obliteration at the time of CWD surgery reduces cavity volume and fills recesses at risk for sequestering epithelial debris

2. Reduction of Cholesteatoma Recidivism

• Obliteration of the mastoid and epitympanum in CWD cavities has been shown to reduce cholesteatoma recurrence and residual disease
• Systematic review of 13 studies (1534 patients): rates of recurrent and residual cholesteatoma in obliterated cavities were only 5.8% and 5.9% respectively
• Obliteration effectively eliminates "dead space" where residual squamous epithelium can hide

3. Difficult or Inaccessible Recesses

• Fills deep recesses (e.g., around the facial nerve, tegmen, sinodural angle) where epithelial debris may accumulate and cannot be cleaned

4. Avoidance of Lifelong Cavity Maintenance

• Patients who are geographically remote, unable to attend regular aural toilet, or unwilling to accept lifelong cavity care
• Patients in whom fitting a hearing aid over an open cavity is difficult
• The final hearing gained after staged ossiculoplasties in CWD mastoidectomies is typically 5-10 dB worse than CWU mastoidectomy due to ineffective sound transmission; obliteration + canal reconstruction can improve this

5. Pediatric Cholesteatoma

• In children, obliteration of the mastoid space (with either CWU or CWD) reduces the unacceptably high revision rate of ~15-20% with CWD/CWU mastoidectomy alone down to 2-3% at 5 years
• Both CWU and CWD surgery present postoperative problems in children; obliteration significantly improves outcomes

B. Secondary Obliteration (Rehabilitation of Pre-existing Cavity)

1. Chronically Draining Mastoid Bowl (Persistent Otorrhea)

• The primary indication for secondary obliteration
• Persistent otorrhea following a prior CWD mastoidectomy that does not respond to:
  • Frequent cleaning (aural toilet)
  • Topical antibiotic therapy
• Series by Bernardeschi et al.: 46 patients obliterated with biosynthetic ceramic - 90% healed and reepithelialized at 1 year with slight improvement in hearing

2. Recurrent Ear Infections / Cavity Infections

• Repeated otitis, especially when cavity cannot be kept dry
• Delayed wound healing after the original CWD surgery

3. Cavity-Related Vertigo

• After CWD mastoidectomy, the semicircular canals may be covered by only a thin epithelial lining
• Thermal/caloric stimulation from wind, water exposure, or suction during cleaning can induce sufficient caloric stimulus to cause vertigo
• Secondary obliteration covers the exposed labyrinth and eliminates these caloric-induced vertigo episodes
• Good outcomes have been reported specifically for this indication

4. Difficulty Fitting a Hearing Aid

• Open mastoid bowls create problems with hearing aid fitting (feedback, poor retention)
• Obliteration + canal reconstruction allows fitting of in-the-canal aids

5. Pre-Cochlear Implantation

• When a patient with chronic suppurative otitis media (CSOM) and a CWD cavity needs cochlear implantation
• Protocol: canal closure + mastoid obliteration first → cochlear implantation 2-6 months later after the cavity has healed
• Major risk to note: cavity obliteration with canal closure carries risk of cholesteatoma formation in the closed space

Summary Table

Contraindications (to note alongside indications)

• Residual/suspected cholesteatoma that cannot be completely removed - obliteration will trap and hide recurrent cholesteatoma
• If cholesteatoma matrix cannot be fully cleared, obliteration is contraindicated (it creates a closed space where cholesteatoma can silently expand)
• Ongoing active infection not yet controlled

Materials Used for Obliteration