Facial paralysis causes incomplete eye closure and impairment of blinking function that can lead to poor tear distribution across the globe, increased tear evaporation, exposure keratopathy, corneal ulceration, and permanent visual loss(Biglioli et al., 2020; Graziani et al., 2011; Joseph et al., 2016; Loyo et al., 2015; Sforza et al., 2008; Vasquez and Medel, 2014).

Ocular surface disruption is caused by decreased frequency and excursion of voluntary closing of the eyelids and the spontaneous blinking reflex, upper eyelid retraction by the non-paralyzed levator muscle, lowering of the lower eyelid resting position, midfacial ptosis, and stretching of the lower eyelid's ligamentous support (Biglioli et al., 2020; Graziani et al., 2011; Vasquez and Medel, 2014).

While healing is anticipated, temporary non-surgical methods are used to protect the ocular surface. Artificial tears, ophthalmic ointments, soft contact lenses, protective tape, occlusive moisture chambers, scleral shells, and external eyelid weights are used routinely (Alsuhaibani, 2010; Bergeron and Moe, 2008; Seiff et al., 1995).

Recent facial palsies include those cases where electromyography detects fibrillations of the mimic muscles. The fibrillations usually stop 18–24 months after the palsy starts. During this time, reanimation surgery aims to provide the facial nerve with new neural supply (Biglioli, 2015).

Blinking is the key mechanism that guarantees the right distribution of tear film and happens spontaneously 10–19 times per minute, while voluntary closure of the eyelid has only a minimal role in corneal lubrication. The therapeutic gold standard of this defect is dynamic reanimation of blinking eyelids by cross facial nerve graft to deliver stimuli from contralateral facial nerve which is the only nerve that can perform such function (Biglioli, 2015; Biglioli et al., 2018; Gousheh and Arasteh, 2011; Peng and Azizzadeh, 2015; Sforza et al., 2008; Terzis and Tzafetta, 2009).

Biglioli et al. used cross-face nerve grafts to restore blinking as apart of triple innervation with masseteric nerve and 30% of the hypoglossal nerve as a comprehensive strategy for management of recent complete facial paralysis(Biglioli et al., 2018).

Results are usually good, but blinking is frequently recovered within a year from the first surgery. Procedures with faster response time are required (Biglioli et al., 2020).

The main purpose of the contemporary surgical techniques is to increase covering of the eye by upper eyelid loading, lower eyelid tightening, and enhancing the ptotic midface. Quality of life is increased when eye function and aesthetics are enhanced(Kim et al., 2018).

In this study, we describe our experience with periocular management in patients with recent complete facial paralysis treated by triple innervation technique. We describe procedures to protect the eye till the effect of reinnervation in the form of blinking and voluntary eye closure is established. Moreover, these procedures would augment the effect of reinnervation by adding protection to the eye.

Our goals were to relax the upper eyelid by loading it with fatty tissue (lipofilling), to support and elevate the lower eyelid by midface suspension with fascia lata to enhance ptosis midface, and to decrees ocular surface exposure and also tighten the lower eyelid by lateral tarsorrhaphy.