Q: Dr. Eppley, I had a craniotomy for an aneurysm over a year ago with radiation. This has left me with many effects from facial nerve paralysis. It has affected my face from the brow the whole down to the neck with a facial droop. I have attached pictures for your assessment. When I lay down my right eye does close which it did not do for quite awhile. The only movement I have on my right temple is a slight lift of the inner tip of the eyebrow. When I try to wrinkle my brow it goes slightly past center but it curves downward. The corner of my mouth was much further down than now. Originally there was no movement at all. I am now able to turn the corner up and the area of movement still seems to be increasing.
A: Thanks for sending your pictures. What they indicate to me is the following:
The frontal branch of the facial nerve is gone which is why the eyebrow does not lift up. As long as the eyebrow has not drifted lower than the opposite normal left side, I would not do any procedure for it. (i.e., browlift)
It is good news that the upper eyelid does now nearly close. As long as it closes completely when you lay down, I would not place a gold weight in the upper eyelid which is the normal treatment for a partial or slow closing upper eyelid.
The lower eyelid, as previously mentioned, needs a procedure which will help it considerably. It needs to be lifted and tightened up against the eyeball. To achieve this more is need to be done than just a traditional lateral canthoplasty. (tightening the lateral canthal tendon at the corner of the eye. That procedure needs to be combined with a fascial sling (harvested from the temporalis fascia) that would be placed from one corner of the eye to the other, much like a clothesline. Together this is the most effective method for lower eyelid tightening and resuspension.
The right face and lower corner of the mouth appears to be in some state of gradual improvement although it is probably not realistic to think that completely normal mouth movement will ever occur. However,, as long as it is improving, I may defer any type of static corner of mouth resuspension until later although that is still up for further evaluation.
The entire right facial droop may be treated with a complete facial resuspension (facelift) on the affected side. That is certainly reasonable to do at anytime. This may be combined with a corner of the mouth lift, both of which will not negatively impact any ongoing facial nerve recovery.
The right temporal area is sunken in due to the effect of the combined craniotomy and radiation, which has caused the temporalis muscle to shrink or atrophy. This is a very common effect from this exact neurosurgical procedure. The temporal area could be built back up using a variety of techniques which would depend on the dimensions of the volume lost. I can not tell exactly from the pictures to give you a better idea on how that would be done yet.
Dr. Barry Eppley