Rehabilitation of the Upper Third of the Face

The main problems to be addressed in this region are improvement of eye closure and correction of laxity of the lower eyelid. Although dynamic muscle procedures have been described to restore eyelid function, most surgeons today rehabilitate the eye with static procedures because they are simple and effective. Inadequate eye closure can be improved by placement of a gold weight in the upper eyelid or insertion of an eyelid spring. Most surgeons prefer gold weight insertion over springs because the procedure is simple and easier to perform. The disadvantage of gold weight is that it requires gravity on the weight of the gold to pull the eyelid down and thus does not work effectively when the patient is supine. The advantage of a spring over gold weight is that its function is not dependent on gravity; therefore, it automatically protects the cornea during sleep. However, it is much more complicated and difficult to place a spring, and the potential for complications is greater. Paralytic ectropion of the lower lid can be corrected by performing wedge excision of the lateral lower eyelid and lateral canthopexy. Severe paralytic ectropion may also require medial can-thopexy. The second, and often overlooked, problem in the upper third of the face is ptosis of the eyebrow, which aside from the obvious asymmetry may result in obstruction of peripheral vision due to lateral hooding. Brow ptosis is corrected with a forehead and brow lift, which can be performed through a forehead incision if the patient has a prominent wrinkle; otherwise, it can be performed endoscopically or through a coronal incision.

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