Upper Eyelid Gold Weight Implantation inthe Asian Patient with Facial ParalysisPhillip H. Choo, M.D., Susan R. Carter, M.D., and Stuart R. Seiff, M.D.Sacramento and San Francisco, Calif.

Patients with facial paralysis may develop ophthalmiccomplications. Poor eyelid closure and lagophthalmosplace the patient at increased risk for the development ofcorneal problems such as epithelial defects, stromal thin-ning, bacterial infection, and even perforation. Initialtreatment should be conservative and include the use ofocular lubricants, moisture chambers, and taping of thelower eyelid into proper position. Surgical interventionmay be required in patients who have failed medical ther-apy or in whom the facial paralysis is not expected toimprove. Gold weight implantation in the upper eyelidhas become a popular procedure to correct upper eyelidretraction and to improve corneal coverage. Previous de-scriptions of gold weight placement in the upper eyelidhave focused on Caucasian eyelid anatomy. However,there are distinct anatomic differences between the Cau-casian and Asian eyelids, which dictate the overlying aes-thetic differences. We describe our technique for place-ment of a gold weight in the Asian upper lid, withattention to the maintenance of symmetric eyelid creases.We reviewed the charts of six Asian patients with facialparalysis who underwent gold weight placement in theupper eyelid for the correction of lid retraction. All pa-tients did well functionally and aesthetically, and nonedeveloped an extrusion of the implant with this approach.(Plast. Reconstr. Surg. 105: 855, 2000.)

Patients with facial paralysis can have numer-ous ophthalmic manifestations including up-per eyelid retraction, lower eyelid ectropion,poor eyelid closure or lagophthalmos, and de-creased tear production. Patients with thesefindings are at increased risk for developingcomplications secondary to corneal exposure,such as epithelial defects, stromal thinning,bacterial infection, and perforation. Initialtreatment includes the use of ocular lubricants,moisture chambers, and taping of the lowereyelid into proper position.1,2 However, some

patients continue to have signs of corneal ex-posure even on maximal medical therapy. Oth-ers are stable on maximal medical therapy, butthe facial paralysis fails to improve, and theyare subsequently faced with the tedious work ofcontinually lubricating the exposed cornea.These two categories of patients are candidatesfor surgical correction of lagophthalmos.2

Gold weight implantation in the upper eye-lid is an effective procedure to correct uppereyelid retraction in patients with facial paralysisand corneal compromise.3–5 Previous descrip-tions of gold weight placement in the uppereyelid have focused on Caucasian eyelid anat-omy.6 However, there are distinct anatomic dif-ferences between the Caucasian and Asian eye-lids, which are responsible for the overlyingaesthetic differences.7–9 Inferior descent of thebrow fat pad or submuscular fibroadipose layerin the Asian eyelid, in combination with a lowinsertion point for the orbital septum, resultsin a low or indistinct eyelid crease and a full-appearing eyelid.10–12 To maintain symmetryand the natural Asian appearance, these ana-tomic differences must be considered when agold weight is implanted into an Asian uppereyelid. We describe our technique and reviewthe results of Asian patients who have under-gone this procedure.

METHODS

Preoperative Assessment

The presence or absence of a crease is notedin both upper eyelids, and the height of thecrease from the eyelid margin is measured.

From the Ophthalmic Plastic and Reconstructive Surgery Service, Department of Ophthalmology at the University of California Davis, andthe Division of Ophthalmic Plastic and Reconstructive Surgery at the Beckman Vision Center and Department of Ophthalmology, University ofCalifornia San Francisco. Received for publication April 26, 1999; revised July 22, 1999.

None of the above authors has any commercial association with the MedDev Corporation.

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The proper size gold weight is then selected forimplantation by taping a progressively largerweight onto the skin of the retracted uppereyelid until lagophthalmos resolves. However,the weight should not be so heavy that it cre-ates a significant ptosis. If further corneal cov-erage is necessary, a lower eyelid tighteningprocedure may be necessary at the same timeas the gold weight placement.

Surgical Procedure

A preexisting eyelid crease is marked with afine-tip marking pen just slightly wider thanthe width of the gold weight chosen for im-plantation. If no crease is present in either ofthe upper eyelids, an incision approximately 3to 4 mm from the upper eyelid margin ismarked. The medial extent of the incisionshould not extend past the superior punctumor into an epicanthal fold because of the riskfor medial canthal webbing. An additionalmark is placed at the margin in line with thecenter of the pupil in primary gaze. The uppereyelid is then injected with anesthetic solution,and the surgical field is prepared and drapedunder sterile conditions.

A 4-0 silk traction suture is placed throughthe upper eyelid margin to retract the lid infe-riorly. An incision through skin and pretarsalorbicularis oculi muscle is made. Dissection iscarried down to the anterior surface of thetarsal plate. If either the submuscular fibroadi-pose layer or the preaponeurotic fat pads areencountered, care should be taken not to ex-cise these structures. Instead, they should beretracted away from the field with a Desmarresretractor to increase visualization.

Once dissection has been made to the ante-rior surface of the tarsal plate, a pocket tohouse the gold weight is made anterior to boththe levator fibers and the tarsal plate. Thepocket should be somewhat larger than theactual size of the gold weight and displacedslightly medial to the center of the pupil inprimary position (Fig. 1, above). During thedissection and creation of the pocket, the at-tachments of the levator aponeurosis to theanterior surface of the tarsal plate should notbe disinserted. Although a limited levator re-cession may be helpful in correcting the uppereyelid retraction, one may cause an iatrogenicptosis. In addition, if facial nerve function im-proves and the weight is removed, the patientmay be left with a residual ptosis. Instead, thegold weight should be placed anterior to the

fibers of the levator aponeurosis as well as thetarsal plate (see Fig. 3).

Interrupted sutures are then placed througheach of the three positioning holes of the goldweight and attached to the tarsal plate withpartial-thickness bites. The eyelid must beeverted and checked for full-thickness suture

FIG. 1. (Above) Dissection has been made to the anteriorsurface of the tarsal plate, and a pocket for the gold weighthas been created. Note the low crease incision and the pres-ervation of the submuscular fibroadipose layer. (Center) Goldweight is secured in place with sutures placed through thepositioning holes and into partial-thickness tarsal plate. Thefibroadipose layer is then brought over the implant beforeclosure. (Below) Immediate postoperative appearance of theright upper eyelid.

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passes. Full-thickness passes may lead to cor-neal abrasions or ulcers, which are extremelydifficult to treat in facial palsy patients. Thethree sutures are then tied sequentially, apply-ing only light pressure. This prevents bucklingof the tarsal plate if there is uneven placementof the sutures in relation to the positioningholes. Once the gold weight is secured inplace, the preaponeurotic fat pads and thesubmuscular fibroadipose layer are broughtover the gold weight (Fig. 1, center). The orbic-ularis muscle layer and skin are then closed asseparate layers (Fig. 1, below).

RESULTS

The charts of six Asian patients with facialparalysis who underwent placement of a goldupper eyelid weight (MedDev, Palo Alto, Cal-if.) were reviewed (Fig. 2). Four women andtwo men, ranging in age from 38 to 82, hadunilateral facial palsies and corneal exposure.Etiology of the facial palsy was idiopathic in twopatients and occurred following intracranial

tumor resection in four patients. The range ofgold weights used was 1.2 to 1.6 g. Follow-upranged from 12 to 60 months, with a mean of26.5 months. All patients experienced an im-provement in corneal epithelial defects andlagophthalmos after placement of the goldweight. Infection, inflammation, migration,and extrusion were not observed in any of thepatients.

DISCUSSION

The Asian upper eyelid crease has receivedmuch attention in the plastic surgery litera-ture.13–25 This interest has been promoted bythe popularity of the Asian blepharoplasty ordouble eyelid surgery. In the past, some au-thors have focused on achieving a “western-ized” or Caucasian appearance.26,27 In our ex-perience, most of the Asian patients whom wehave consulted for an upper blepharoplastyhave wanted to maintain their Asian appear-ance.

The difference between the Asian and theCaucasian upper eyelid crease is dictated bythe difference in the underlying anatomy. Theupper eyelid crease forms at the highest pointof attachment of the levator aponeurosis to thesubcutaneous tissue. In Caucasians, the orbitalseptum inserts onto the anterior surface of thelevator aponeurosis above the superior borderof the tarsal plate and holds the preaponeuro-tic fat pads in place. This allows the anteriorfibers of the levator aponeurosis to extend tothe subcutaneous tissue at or above the supe-rior border of the tarsal plate and to create ahigh upper eyelid crease.

In Asians, the brow fat often descends infe-riorly as the submuscular fibroadipose layer(Fig. 3). This layer provides fullness to theupper eyelid, acts as a barrier between theanterior fibers of the levator aponeurosis andthe subcutaneous tissue, and prevents the for-mation of a high eyelid crease. Furthermore, inAsians the insertion site of the orbital septumonto the anterior surface of the levator apo-neurosis is variable. In this area, the septumbecomes diffuse and less prominent, allowingfor the inferior descent of the preaponeuroticfat pads. It is this combination of a prominentsubmuscular fibroadipose layer, weak inferiorseptum, and the inferior descent of thepreaponeurotic fat pads that can either pre-vent the formation of an eyelid crease (singleeyelid) or create a low crease (double eyelid).

These anatomic differences need to be con-

FIG. 2. (Above) Same patient 3 months after gold weightimplantation in the right upper eyelid. Note the preservationof the single upper eyelid crease and the epicanthal fold tomaintain the Asian appearance of this patient. (Below) Samepatient on attempted eyelid closure.

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sidered when planning gold weight placementin the Asian patient. One should focus onmaintaining symmetry with the unaffected sideand take special steps during the procedure tomaintain a low or single eyelid crease. First,one should avoid a high incision (generally 8to 10 mm from the lash margin in the Cauca-sian eyelid), which may promote a bifid or a“westernized” crease. Instead, the incisionshould be kept low (3 to 4 mm from the lashmargin) or at a preexisting crease if present(Fig. 3).

Furthermore, one may encounter brow fat(submuscular fibroadipose layer) as well as thepreaponeurotic fat pads during dissection to-ward the anterior surface of the tarsal plate. Ifthis occurs, the brow fat and the preaponeuro-tic fat pads should be preserved. These layersact as a barrier between the anterior fibers ofthe levator aponeurosis and the overlying der-mis and prevent the formation of an unwantedeyelid crease above the incision. In addition,

these layers help to prevent an anterior extru-sion of the gold weight implant and counteractupper eyelid retraction by providing an extraweight load. Another difference in techniquebetween the Asian and Caucasian eyelids is thelocation of the gold weight implantation. InCaucasian eyelids, some surgeons prefer toplace the gold weight high in the lid to reducevisibility of the weight. However, the weight inthe Asian eyelid can be placed lower because itis camouflaged by both the preaponeurotic fatpads and the fibroadipose layer (Fig. 3).

One criticism of the above technique may bethe low incision. Catalano et al.28 stated theimportance of not overlapping any portion ofthe implant to prevent an extrusion. In ourseries, none of the patients has developed anextrusion. However, this is a serious concern,and we try to prevent this by covering part ifnot all of the implant with the submuscularfibroadipose layer and the preaponeurotic fatpads. Next, we advocate meticulous closure of

FIG. 3. This diagram illustrates some of the differences between the Caucasian and Asianupper eyelids. Both the preaponeurotic fat pads (P) and the fibroadipose layer (F) descend moreinferiorly in the Asian upper eyelid. The white arrows point to recommended incision sites for goldweight implantation. Notice that the incision should be made lower in the Asian eyelid. Inaddition, the gold weight (white rectangle) may be placed slightly lower on the tarsal plate in theAsian eyelid. In both cases, however, the gold weight is placed anterior to both the tarsal plateand the inferior fibers of the levator aponeurosis, which insert onto the surface of the tarsal plate.

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the orbicularis muscle and the overlying skin intwo separate layers. In conclusion, with carefulattention to the anatomic differences betweenAsian and Caucasian eyelid anatomy, one canimplant a gold weight in the Asian upper eyelidto improve function while preserving the nat-ural appearance of the Asian patient.

Phillip H. Choo, M.D.University of California Davis Medical CenterDepartment of Ophthalmology4860 Y. Street, Suite 2400Sacramento, Calif. 95817phchoo.@ucdavis.edu

ACKNOWLEDGMENT

This work was funded in part by the Research to PreventBlindness Foundation.

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