Indian Journal of Ophthalmology

: 1994  |  Volume : 42  |  Issue : 3  |  Page : 153--156

Lid load operation in facial palsy

K Muller-Jensen 
 Stadt Karlsruhe Klinikum, Akademisches Lehrkrankenhans der Universitat Freiburg

Correspondence Address:
K Muller-Jensen
Stadt Karlsruhe Klinikum, Akademisches Lehrkrankenhans der Universitat Freiburg


In 24 patients with irreversible lagophthalmos, gold weights ranging from 0.8 to 1.7 g were implanted in the upper lids, under local anaesthesia. With a follow-up period ranging from 2 1/2 to 4 years (average, 3 years), the results of the implantation were gratifying in 23 patients. While corneal irritation and epiphora was reduced and the loaded upper eyelid allowed patients to blink voluntarily

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Muller-Jensen K. Lid load operation in facial palsy.Indian J Ophthalmol 1994;42:153-156

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Muller-Jensen K. Lid load operation in facial palsy. Indian J Ophthalmol [serial online] 1994 [cited 2020 Oct 27 ];42:153-156
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Facial palsy may lead to severe functional and cosmetic defects. The main problem is the staring non­ winking eye with its wide palpebral fissure and the frequently exposed lower lid conjunctiva due to ectropion. Lid closure is not possible as the orbicularis oculi is paralysed [Figure 1].

The main causes [1],[2] for facial paralysis are many [Table 1] and the therapy in general is unsatisfactory. Eye patches and moist chambers disturb vision. Blepharorrhaphies and ectropion operations do not restore the upper lid function [3][4][5][6][7][8] [Table 2]. More sophisticated operations such as magnet implantation[4] and metal spring implantation[5] lead to a high rate of complications, especially extrusion of implants. Circular silicone band implantation by Arion et all provokes blepharophimosis without complete lid closure. Muscle and nerve transfers by Masters et al; Conley and Baker' are not always successfull.

A relatively simple method to cure lagophthalmos is lid loading by precious metal implantations. This technique was first performed by Ambos [8] in 1957 and a year later by Illig, [10] both in Germany. About 20 years later, plastic surgeons, Jobe[11] and May [12] practiced this technique on many patients in the United States.

We modified this procedure and applied it to 24 patients with irreversible lagophthalmos.


Twenty-four patients with irreversible lagophthalmos caused by different diseases [Table 3] were included in the study. Initially, lead weights ranging from 0.8 to 1.7 g were glued to the centre of the upper lid overlying the tarsal plate. The ideal weight produces complete voluntary closure and opening of the lids without awareness of heaviness. The ideal weight was then made from 24 carat gold which is well tolerated by the tissue. The gold implant is not bulky, well rounded, and conforms to the corneal curvature. The two holes at the lateral ends are for the sutures [Figure 2].

The operations were done under local anaesthesia. A 5-mm incision was made in the upper lid fold. After preparation of a pocket under the orbicularis muscle, the gold weight was sutured to the levator aponeurosis by 6-0 prolene, partially positioned on the tarsal plate [Figure 3][Figure 4]. The orbicularis wound was closed by 6-0 vicryl and the skin wound by 6-0 silk.

In 16 patients the functional and cosmetic result was optimized by additional procedures such as lateral and medial blepharorrhaphy, ectropion operation, or brow-lift.


The operation was well tolerated in all cases. The cosmetic appearance was acceptable though the implant was partly visible through the skin when the lids were closed [Figure 5] The implant was not visible when the lids were open [Figure 6]. Within the first 3 weeks of implantation, extrusion was observed in two cases. After reimplantation (case 3) into a deeper pocket, the healing was complete and there were no more signs of extrusion. The second patient (case 4) refused further surgery.


Lid loading has the merit of simplicity and reversibility. The patient can close the eye almost completely in the immediate postoperative period. The blinking reflex is restored and the eye remains clear. The main disadvantage of lid loading is the dependance on gravity. It does not eliminate the necessity for nocturnal corneal protection with eye patches or ointments. However, when eyelid loading is combined with other procedures, protection of the cornea at night may not be necessary. Elevation of the head at night and pressing the pillow against the closed lids is often helpful after lid loading.

After an average follow-up period of 12 months, we did not encounter any serious corneal complications in any of our patients.

Extrusion of implants in the early phase of wound healing occurs rarely. This complication is minimised with adequate technique, especially when implanted in deeper process. May° did not encounter any extrusion in his 84 patients.

Decentration of the gold weight, which seems a very rare late complication, can lead to incomplete lid closure. Recentration and resuturing of the prothesis was necessary in an 80-year-old patient (case 12) with flabby tissue, 6 months after implantation. After reoperation the lid function was restored.

In summary, lid loading is a safe, inexpensive, effective, and ingeniously simple method to cure lagopthalmos with rare complications. Our experience in 24 patients in whom we implanted gold weights ranging from 0.8 to 1.7 g in the upper lid was gratifying. While corneal irritation and epiphora was reduced, the loaded upper eyelid allowed patients to blink voluntarily.


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