Facial nerve (cranial nerve VII) paralysis is a common condition encountered by otolaryngologists and facial plastic surgeons. Management often requires a multidisciplinary approach involving ophthalmology, neurology, head and neck surgery, and facial reanimation specialists. Protecting the ocular surface is the immediate priority, as lagophthalmos and impaired blink can lead to exposure keratopathy, corneal ulceration, stromal scarring, and permanent vision loss if left untreated.
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September 2026“Our first priority is always protecting the eye because ocular complications have one of the greatest impacts on quality of life in patients with facial paralysis,” said Deanna C. Menapace, MD, a facial plastic and reconstructive surgeon at Mayo Clinic Florida.
ENTtoday spoke with leaders in facial nerve reconstruction about current approaches to evaluating and managing ocular complications associated with facial nerve paralysis.
Etiology
The etiological spectrum for facial nerve paralysis is broad. The most common cause is Bell’s palsy, an idiopathic peripheral facial palsy presumed to be viral in origin. More than two-thirds of patients have spontaneous complete facial nerve recovery (Am Fam Physician. https://tinyurl.com/59zz5k9p). Many develop aberrant reinnervation, however, resulting in various patterns of synkinetic movement characterized by involuntary, uncoordinated ipsilateral muscle contractions and spasms.
Other causes of facial paralysis include skull base and parotid tumors, temporal bone trauma, cutaneous malignancies, Lyme disease, Ramsay Hunt syndrome, sarcoidosis, cholesteatoma, congenital disorders, and nerve entrapment. Because prognosis and treatment vary considerably by etiology, identifying the underlying cause is critical.
Anatomy and Ocular Consequences
Facial nerve paralysis results in denervation of the orbicularis oculi and the muscles of facial expression, impairing blink, voluntary eye closure, and facial movement. Loss of blink function disrupts tear film distribution and clearance, leading to inadequate lubrication, reflex tearing, and ocular surface disease.
Loss of orbicularis tone and midfacial support also predisposes the lower eyelid to ectropion. The resulting widening of the palpebral fissure increases scleral exposure and further compromises corneal protection.
The levator palpebrae superioris muscle, which is responsible for opening the eye, is innervated by the third cranial nerve. As a result, patients are usually able to open their eyes without difficulty. Typically, the sensation in the eye, provided by the fifth cranial nerve, remains intact; however, in certain situations, such as during surgical treatment for a malignancy near the skull base, the sensory function can be compromised.
Sherard A. Tatum III, MD, warned that this can be a particularly dangerous situation that needs closer monitoring because patients don’t experience eye irritation, even when keratopathy might be quite severe. Dr. Tatum is an ENT double-boarded in facial plastic and reconstructive surgery and otolaryngology at SUNY Upstate Medical University in Syracuse, N.Y.
“The eye is very delicate, and it depends on its lids to protect it and keep it moist,” he said. “If the eye dries out, it can ulcerate and rupture, and that’s catastrophic.”
Ophthalmology Evaluation
Initial evaluation begins with a careful assessment of eyelid closure and blink function. Patients should be questioned about ocular irritation, dryness, blurred vision, excessive tearing, and pain. Physical examination should assess conjunctival injection, discharge, lagophthalmos, ectropion, and corneal clarity and sensation.
Daniel E. Rubinstein, MD, is an ophthalmologist and oculofacial surgeon with ECU Health in Greenville, N.C. For initial ophthalmologic evaluation, he recommended that even clinicians without specialized ophthalmic equipment perform a basic corneal examination using a penlight. “Areas of corneal opacity or surface irregularity should prompt urgent ophthalmologic evaluation, because they may indicate significant exposure-related inflammation,” he said.
Although an initial bedside examination is essential, long-term ophthalmologic follow-up is equally important, noted J. Madison Clark, MD, FACS, an ENT double-boarded in facial plastic and reconstructive surgery and otolaryngology at UNC Health in Chapel Hill, N.C.
Dr. Clark said, “Often patients can have injury to the cornea without even having bothersome symptoms like itchy eyes or the grainy, sandy feeling in the eyes. With a slit lamp exam, an ophthalmologist can see damage to the cornea even before the patient has symptoms.”
Conservative Interventions
The primary goal of conservative treatment is preservation of the ocular surface through aggressive lubrication and protection. Many patients with mild facial paralysis can be managed successfully without surgery.
Preservative-free artificial tears should be used frequently throughout the day to maintain corneal lubrication. Dr. Menapace generally recommends application at least three to five times daily, although patients with more severe symptoms often require more frequent dosing.
Nighttime management is particularly important because blink-mediated tear redistribution ceases during sleep. Liberal application of ophthalmic lubricating ointment or gel helps prevent overnight corneal desiccation. Lagophthalmos may worsen in the supine position, making nocturnal protection especially critical.
At night, Dr. Menapace also strongly recommended using moisture chambers over the eye. “A moisture chamber essentially creates a humidified environment around the eye while also protecting it from accidental trauma during the night,” she said.
Although eyelid taping and eye patches may also be used, she generally finds that moisture chambers provide more consistent protection and humidification.
Scleral contact lenses represent an additional nonsurgical option for patients with persistent exposure keratopathy. These large-diameter gas-permeable lenses create a fluid reservoir over the cornea, maintaining continuous hydration and protecting the ocular surface. Because they require specialized fitting, referral to an experienced contact lens specialist is necessary. Dr. Rubinstein considers scleral lenses particularly useful for patients with refractory exposure keratopathy who are poor surgical candidates or who wish to delay surgery.
Dr. Rubinstein also recommended punctal occlusion as a quick, minimally invasive procedure that can be performed in the outpatient setting. Silicone punctal plugs reduce tear drainage through the lacrimal system, increasing tear retention and improving ocular surface hydration.
A key part of conservative management is good patient education. Taha Z. Shipchandler, MD, an ENT double-boarded in facial plastic and reconstructive surgery and otolaryngology at IU Health in Indianapolis, advises patients to seek prompt medical attention if they experience eye redness, scratchiness, dryness, a lack of sensation, pain, visual disturbance, or excess tearing.
Dr. Shipchandler explained that many patients falsely believe that it’s a good sign if their eyes are watery, and they might not use their artificial tears as much. “But that’s often just a sign that their eyes are in overdrive trying to protect the eye,” he said.
Timing and Choice of Procedural Approaches
When conservative management fails to adequately protect the eye, surgical intervention should be considered. Advances in facial reanimation have expanded treatment options and improved both functional and aesthetic outcomes. Selecting the appropriate procedure requires careful consideration of the cause of paralysis, duration of symptoms, anticipated recovery, corneal health, facial anatomy, and patient goals.
“If it’s Bell’s palsy, you protect the eye, and then you wait and see,” Dr. Tatum said. “If it was a tumor resection, then there’s no point in waiting, because we’re not anticipating that the problem is going to improve on its own.”
For patients undergoing tumor resection that requires facial nerve sacrifice, Dr. Menapace recommends considering primary nerve repair or nerve transfer as part of the same operation.
Corneal status is one of the most important factors influencing treatment urgency, due to impaired eye sensation. Dr. Shipchandler also noted that it’s key to intervene early and more aggressively for an eye that is already very red, inflamed, and at risk.
Treatment decisions should also incorporate patient preferences. Some individuals prioritize facial symmetry and aesthetics, whereas others are willing to adopt additional maintenance with lubrication or moisture chambers to delay surgery. Shared decision-making is therefore an important component of management.
Static Versus Dynamic Procedures
Reconstructive procedures can be broadly categorized as static or dynamic. Many patients ultimately benefit from a combination of both.
Static procedures improve eyelid position, protect the cornea, and restore facial symmetry at rest but do not generate active movement. These procedures generally have predictable outcomes and relatively low morbidity and can often be performed under local anesthesia. Static procedures may serve as definitive treatment or as adjuncts while patients await nerve recovery or dynamic reanimation.
In contrast, dynamic procedures restore active facial movement by reestablishing neural input to the facial musculature. Although they offer the potential for improved facial function, they are technically more demanding and require careful patient selection; often, meaningful movement is not observed for several months.
“We typically favor dynamic reanimation techniques if those are available and will work in the specific patient,” Dr. Shipchandler said.
“If the cornea is in poor health, you may consider doing one of these static procedures while you’re waiting for the other cross innervation or other methods of reconstruction to mature,” Dr. Clark said.
“You don’t depend on one method to do everything,” Dr. Tatum said. “A patient might get a combination of eyelid surgery—which works immediately to protect the eye—and then some other procedures to give you more movement and facial nerve function long term.”
Static Procedures Around the Eye
Tarsorrhaphy
All otolaryngologists managing facial paralysis should be comfortable performing a basic tarsorrhaphy to protect the eye in patients with acute, vision-threatening presentations, Dr. Tatum noted. Partial lateral tarsorrhaphy is most commonly performed, although more extensive eyelid closure may occasionally be required to adequately protect the cornea.
Because of aesthetic and functional concerns, this approach is usually performed as a temporary measure while awaiting recovery or definitive reconstruction. But Dr. Tatum noted it may also be used as a more permanent option in some patients, such as those who are poor candidates for more extensive procedures or who have lost meaningful use of the eye.
For patients with persistent ocular surface disease despite maximal conventional therapy, autologous serum eye drops have emerged as an additional treatment option. “Autologous serum tears have regenerative potential, and we’ve had encouraging results in patients with moderate-to-severe dry eye related to facial paralysis,” Dr. Menapace said.
Upper eyelid procedures
For patients who need procedural interventions to protect their eyes from damage from incomplete closure, gold or platinum weight surgical placement on the upper eyelid is the most typical intervention, Dr. Tatum explained, although removable stick-on weights can be used instead.
After the physician identifies the exact weight needed for the patient, the implantable device allows the upper eyelid to close with gravity. Because of this reliance on gravity, these implants may be less effective when patients are lying supine. Dr. Rubinstein noted, however, that they have drawbacks like potential migration and induced ptosis.
“Patients immediately find relief when placing that eyelid weight, because they’re getting a more effective blink and more coverage of the eye,” Dr. Menapace said. “Combined with lower eyelid tightening when indicated, eyelid weights provide substantial functional benefit with relatively little morbidity.”
Future directions in upper eyelid management for facial paralysis include the development of more physiologic and patient-specific alternatives to traditional eyelid weights. These may include autologous and novel synthetic implant materials, injectable eyelid-loading strategies, neuromodulation techniques, and emerging bioelectronic therapies aimed at restoring coordinated blink function.
Lower eyelid procedures
Management of paralytic lower eyelid malposition focuses on restoring eyelid support, improving globe apposition, and reducing ocular exposure.
The lateral tarsal strip procedure remains the cornerstone of lower eyelid reconstruction. By shortening and repositioning the lower eyelid, it corrects horizontal laxity, improves eyelid position, and enhances corneal protection. A lateral canthotomy and cantholysis are typically performed to achieve optimal eyelid tension and cosmetic outcomes. In patients with significant structural deficiency, a posterior spacer graft, most commonly using auricular cartilage, can provide additional support.
For patients requiring more extensive reconstruction, a Hughes tarsoconjunctival flap may be used to restore posterior lamellar support. Dr. Shipchandler and colleagues have developed a modified version of this technique that connects the upper eyelid to the posterior lamella of the lower eyelid while preserving a more natural appearance (JAMA Facial Plast Surg. doi:10.1001/jamafacial.2018.0070).
Dr. Shipchandler said, “When a patient with an upper eyelid weight lies down, the upper eyelid does not fall back as much because it’s connected to the lower lid. When it falls back a little, it pulls the lower lid with it to provide greater protection.”
The bipedicled orbicularis oculi myocutaneous (BOOM) flap, developed by Dr. Clark and colleagues, is an additional procedure that can be added to support the lower eyelid for very severe or recurring cases of paralytic ectropion from facial nerve palsy (JAMA Facial Plast Surg. doi:10.1001/jamafacial.2018.1704).
The technique uses a strip of skin and the underlying orbicularis oculi muscle from the upper eyelid. The flap is interpolated downward to the lower eyelid without detaching either of its ends and inserted into the lower eyelid into a space made just below the lower lid lash line. “It’s like a bucket handle. Where it’s attached, it pulls back and up to bring the lower eyelid up and against the eyeball,” Dr. Clark said.
For very severe cases, Dr. Clark adds a posterior spacer graft along with a modified tarsoconjunctival flap and couples that with the BOOM flap. “Between those three things, that is about the most powerful treatment that we can offer surgically for patients with extremely severe paralytic ectropion,” he said.
Importantly, these procedures substantially improve eyelid position and ocular protection, but they do not restore a natural blink. “Still, we can make things better and safer for patients and their eyes,” Dr. Shipchandler said.
Additional static procedures, including fascia lata or palmaris longus suspension slings and midface lifting, may improve resting facial symmetry while indirectly enhancing lower eyelid support.
Patients with long-standing facial paralysis may also develop aberrant reinnervation of the periocular muscles, resulting in hypertonicity, spasm, and narrowing of the palpebral fissure. In these patients, selective myectomy or chemodenervation with botulinum toxin can improve both function and facial symmetry.
“There is no time limit for initiating neuromodulator treatment,” Dr. Menapace said. “Even patients many years after facial paralysis can achieve meaningful improvement in facial symmetry and function.”
Dynamic Procedures
Unlike static procedures, dynamic facial reanimation restores active facial movement through reinnervation of the native musculature or muscle transfer. Because facial muscles progressively lose their ability to respond to neural input after prolonged denervation, timing is critical.
For example, for the minority of patients with facial nerve paralysis from a transected facial nerve, primary nerve repair should be performed as quickly as possible.
Dr. Menapace emphasized that all patients with partial paralysis or incomplete recovery should be evaluated by a facial reanimation specialist within three to six months of their diagnosis. A similar time frame should be followed in patients without signs of recovery, she noted.
She shared, “We monitor these patients closely with serial examinations, electromyography, videography, and computer-based facial mapping when appropriate to assess whether spontaneous recovery remains likely and to determine the optimal timing for intervention.”
For patients without meaningful recovery by approximately six months, nerve transfer procedures should become part of the discussion.
“We used to believe there was a much longer window before intervention was necessary,” Dr. Menapace said. “More recent evidence suggests that earlier nerve reconstruction leads to better functional outcomes.”
Nerve switch procedures
Nerve transfer procedures restore neural input by redirecting functioning nerves to the paralyzed facial musculature. Although reinnervation requires several months, these procedures can produce meaningful improvements in facial movement.
In Dr. Menapace’s experience, a relatively high percentage of patients can achieve functional recovery via nerve switch procedures, although outcomes are influenced by factors such as patient age, duration of paralysis, prior radiation therapy, and active malignancy.
Free muscle transfers
Patients with long-standing facial paralysis eventually lose the ability to reinnervate their native facial muscles. In these cases, free functional muscle transfer, most commonly using the gracilis muscle, provides an opportunity to restore dynamic facial movement.
“If you go more than a year without innervation to the muscles of the face, they generally lose the ability to be reinnervated. That’s when you have to replace the muscle,” Dr. Tatum said.
One emerging technique involves transferring the orbicularis oculi muscle from the contralateral eyelid (Orbit. doi:10.1080/01676830.2021.1942500). This might restore a functional blink reflex, unlike other existing techniques, but outcome data are still variable, though promising. Dr. Rubinstein said, “This technique does carry a risk of incomplete blink and paralytic lagophthalmos of the contralateral side.”
Encouraging Referral to Facial Reanimation Specialists
Advances in facial reanimation have dramatically expanded treatment options for patients with facial paralysis. Although it’s not always possible to completely restore normal function, treatment can always improve comfort, facial symmetry, eye protection, and quality of life.
Although certain procedures are time-sensitive, Dr. Shipchandler emphasized that all patients with facial nerve palsy can be treated to improve their quality of life. The field is nuanced, he noted, so patients should ideally be evaluated by an expert in facial reanimation techniques.
Dr. Shipchandler shared that some of his patients are not referred to experts because clinicians assume little can be done once paralysis becomes chronic, but that simply isn’t true.
“Facial nerve palsy is devastating for patients,” he said. “Some people don’t want to look at themselves in a mirror or get a family photo. But we can absolutely make their lives much better.”
Ruth Jessen Hickman, MD, is a graduate of the Indiana University School of Medicine. She is a freelance medical writer living in Bloomington, Ind.
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