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Trans-nasal Tendon Suspension for the Paralyzed Lower Eyelid
Abstract
Paralytic ectropion is a significantly functional and esthetic problem leading to problems with lacrimation, corneal exposure, and poor palpebral closure. Limitations with traditional corrective procedures include poor apposition of the lid to the globe, suboptimal medial canthal position, and high recurrence rates.
The objective of this study was to develop a technique of lower-lid suspension using transnasal wiring for the long-term maintenance of lid position.
Twenty-three consecutive patients with complete unilateral facial nerve paralysis underwent the procedure, and they were followed up for a median of 27 months (1-73 months).
Fifteen of 18 patients maintained their intraoperative lower-lid position beyond the 12-month follow-up. Three patients had a minimal scleral show at 3 months. One of these patients also developed lid laxity seen on the snap test. No perioperative complications were experienced.
Transnasal wiring of the lower-lid tendon suspension provides consistent results that are maintained over time.
Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
... It is important that lower eyelid reconstruction achieves lower eyelid stability with the suspension and fixation procedure. As for lower eyelid suspension, many reports have been published [7][8][9][10][11]. In most of those reports, the procedures to prevent ectropion provided a structural strengthening in the horizontal direction using materials such as fascia, periosteum, and tendon tissue [7][8][9][10][11]. ...
... As for lower eyelid suspension, many reports have been published [7][8][9][10][11]. In most of those reports, the procedures to prevent ectropion provided a structural strengthening in the horizontal direction using materials such as fascia, periosteum, and tendon tissue [7][8][9][10][11]. On the other hand, as canthal fixation, suturing to the periosteal surface or a hinged periosteal flap, drilling and wiring to the orbital bone, and an anchor screw fixation have been reported in the past [12][13][14], the structural strengthening in the horizontal direction and the steady canthal fixation contribute to achieving the natural sharp canthus shape. ...
Extensive full-thickness defects of both the upper and the lower eyelids continue to be a challenge for reconstructive surgeons. Ectropion of the lower eyelid and an unnatural canthal shape are pitfalls to be avoided in total eyelid reconstruction. We here present a case in which an extensive full-thickness defect of the upper and lower eyelids after tumor resection was successfully reconstructed by means of periosteal flap canthoplasty from the infraorbital margin. A 73-year-old woman had in situ melanoma on her left eyelids. The lids were almost completely removed as a result of tumor resection. The conjunctival defect was covered with oral mucosa. And the tarsal layer was reconstructed with auricular cartilage. A periosteal flap pedicled at the origin of the lateral canthal tendon was harvested from the infraorbital margin. The flap was fixed with sutures on the cartilage graft for the lower eyelid. The cartilage graft for the upper eyelid was sutured laterally on the basal portion of the periosteal flap as the lateral canthus. The skin defect of the upper eyelid was covered with a bipedicled orbicularis oculi flap and skin graft. The lower eyelid was reconstructed with a combination of an angular artery transposition flap and a cheek rotation flap. Thirteen months after the surgery, the reconstructed eyelids had good function without ectropion. And the reconstructed canthus had a natural sharp shape. Total eyelid reconstruction using periosteal flap canthoplasty combined with auricular cartilage and oral mucosa grafts is useful for extensive full-thickness defects of the upper and lower eyelids.
Level of evidence: Level V, therapeutic study.
... A drawback of this procedure is the less desirable effect to address the laxity when it is predominantly in the medial canthus. Some authors recommend lower lid tightening from the nasal side as part of the main procedure, 33,34 or as a supplemental surgery. 2,8,11 Although most authors prefer a lateral lid tightening, an augmenting medial tightening procedure has been reported as well. ...
Purpose
To report the effect of lower eyelid temporalis fascia sling combined with lateral canthoplasty and tarsorrhaphy for paralytic ectropion.
Methods
Prospective case series of 10 patients with lower lid paralytic ectropion who were treated with lower eyelid fascia temporalis sling and lateral canthoplasty in addition to lateral tarsorrhaphy as a single-session procedure. Additional medial tarsorrhaphy was applied if the medial lower lid apposition was not adequate at the end of the procedures. Eyelid configuration and function were compared before and after surgery.
Results
The mean age of patients was 65.8 ± 10 years. Mean marginal reflex distance 1 (MRD1) and MRD2 changed from 3.5 ± 1.4 and 8.6 ± 2.4 mm to 2.2 ± 1.4 and 5.3 ± 1.2 mm respectively (p = 0.001 and 0.006). Mean pre-operative lagophthalmos improved from 9.2 ± 4.9 to 3.4 ± 1.3 mm (p = 0.001). The mean follow-up was 28.9 ± 12.1 months. Three patients required additional medial tarsorrhaphy to address residual medial ectropion in the same session.
Conclusion
Combination of lower lid fascia temporalis sling, lateral canthoplasty and tarsorrhaphy as a single-session procedure can effectively improve the functional and aesthetic complications of paralytic ectropion.
... However, the long-term maintenance result was based on the physician's subjective finding. 2,[5][6][7][8][9][14][15][16] In this study, we compared the sling method and the supporting midface lift technique. Among the three groups, the midface lift group had the lowest 836e Plastic and Reconstructive Surgery • April 2019 ratio between the distance from the pupil center to the eyelid margin on the paralyzed side and the distance on the normal side. ...
Background:
Restoration of paralytic lower eyelid retraction is challenging in the surgical management of facial paralysis. In this study, quantitative measurements were compared between the suspension sling and lower eyelid-supporting midcheek lift techniques.
Methods:
From 2014 to 2016, 36 operations were performed on 28 patients with a mean age of 45.6 years (range, 7 to 80 years), a mean denervation time of 13.5 years (range, 0.2 to 44 years), and a mean follow-up period of 636 days (range, 261 to 1143 days). The surgical techniques included autologous tendon sling (n = 9), Mitek suspension (n = 12), and midcheek lift (n = 15). The distance from the pupil center to the lower eyelid margin was measured, and the ratio of the distance on the paralyzed side to that on the normal side was analyzed.
Results:
The change in the ratio between the paralyzed side and the normal side was 0.098 (from 1.264 to 1.166; p = 0.353) in the autologous tendon sling group, 0.104 (from 1.231 to 1.127; p = 0.243) in the Mitek suspension group (p = 0.05), and 0.179 (from 1.234 to 1.055; p = 0.038) in the midcheek lift group. Two patients in the Mitek suspension group developed foreign body infection.
Conclusions:
The midcheek lift group showed the greatest change in the ratio between the distance from the pupil center to the eyelid margin on the paralyzed side and that on the normal side. Eyelid-supporting midcheek lift is superior to suspension sling for restoration of paralytic eyelid retraction.
Clinical question/level of evidence:
Therapeutic, III.
Lower eyelid suspension, a common therapeutic procedure for facial paralysis-induced eyelid retraction, faces challenges due to high recurrence in patients lacking facial muscle function and impedes wider adoption. This research aims to explore the potential effects of restoring orbicularis oculi muscle tension through facial nerve reanimation prior to lower eyelid suspension and to define the indications for lower eyelid suspension.
The study encompassed 32 individuals with complete facial paralysis, segmented into group A (reanimation group) and group B (non-reanimation group), based on whether the orbicularis oculi muscle’s tension was restored through facial nerve reconstruction prior to lower eyelid suspension. Subjective assessments of eyelid closure (the inter-eyelid gap upon gentle closure) and objective methods measures of scleral show (the distance from the pupil’s center to the lower eyelid margin, MRD2) were used to provide a comprehensive analysis of long-term effectiveness.
The group A exhibited significantly greater long-term improvement in lagophthalmos and lower eyelid ectropion. The alterations in MRD2 measured 2.66 ± 0.27 mm in the group A versus 2.08 ± 0.53 mm in the group B, denoting a statistically significant variance (p < 0.001). Moreover, while the ratio of MRD2 preoperative 6 months postoperative revealed no significant difference between groups, a significant difference emerged in 12 months postoperative (group A: 1.02 ± 0.21; group B: 1.18 ± 0.24; p < 0.05), with the values in group A closer to 1, indicative of enhanced symmetry.
Restoring the tension in the orbicularis oculi muscle through facial nerve reconstruction prior to palmaris longus tendon sling could effectively sustain long-term outcomes of lower eyelid retraction correction and reduce the recurrence rate.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Background:
Paralytic ectropion increases risk for corneal injury in facial palsy patients. While a lateral tarsal strip (LTS) provides corneal coverage through supero-lateral lower eyelid pull, the unopposed lateral force may result in lateral displacement of the lower eyelid punctum and overall worsening asymmetry. A tensor fascia lata (TFL) lower eyelid sling may overcome some of these limitations. This study quantitatively compares scleral show, punctum deviation, lower marginal reflex distance (MRD), and peri-orbital symmetry between the two techniques.
Methods:
Retrospective review was performed on facial paralysis patients who underwent a LTS or TFL sling with no prior lower lid suspension procedures. Standardized pre- and post-operative images in primary gaze position were used to measure scleral show and lower punctum deviation using ImageJ, and lower MRD using Emotrics.
Results:
Of 449 facial paralysis patients, 79 met inclusion criteria. Fifty-seven underwent a LTS and twenty-two a TFL sling. Compared to pre-operatively, lower medial scleral show significantly improved with both LTS (10.9 mm2, p<0.01) and TFL (14.7 mm2, p<0.01). The LTS group showed significant worsening of horizontal and vertical lower punctum deviation when compared to the TFL group (both p<0.01). While the LTS group failed to achieve periorbital symmetry between the healthy and paralytic eye across all parameters measured post-operatively (p<0.01); the TFL group achieved symmetry in medial scleral show, lateral scleral show, and lower punctum deviation.
Conclusions:
In patients with paralytic ectropion, TFL sling provides similar outcomes to LTS with added advantages of symmetry without lateralization or caudalization the lower medial punctum.
Correction of lower eyelid retraction is necessary to restore adequate blink in paralytic lagophthalmos. A plethora of static and dynamic surgical techniques have been described for lower eyelid repositioning. This article provides an approach to management of the paralytic lower eyelid, including a summary of existing techniques, case examples, and surgical technique for in-office lower eyelid suspension using a palmaris longus tendon graft.
Background: Lateral tarsal techniques alone for lower eyelid correction in paralytic lagophthalmos may yield suboptimal outcomes. Objective: To describe a lower eyelid sling technique for primary and revision correction of lower eyelid ptosis and ectropion and evaluate outcomes as measured by margin reflex distance 2 (MRD2). Methods: A retrospective review of patients with long-standing unilateral paralytic lagophthalmos who underwent primary or revision lower eyelid ptosis correction by sling suspension between January 2016 and August 2020 at a tertiary medical center was performed. Surgical technique is illustrated with video and technical considerations are discussed. Pre- and postoperative MRD2 values were quantified from databased photographs. Results: Thirty-eight patients were included. Eighteen patients had undergone prior procedures for ptosis correction. Lower eyelid symmetry and paralyzed side MRD2 significantly improved after lower lid sling for primary and revision cases (p < 0.05), and improvement was sustained over the study period (mean follow-up duration 13.3 months, range 1-33 months). No postoperative complications occurred. Conclusion: Lower eyelid sling yielded safe, effective, and durable correction of lower eyelid position in a cohort of patients with paralytic lagophthalmos.
Static facial sling procedures are one of many facial reanimation options to address long-standing and irreversible facial paralysis. The primary goals of static reanimation are to provide symmetry at rest and improve static function at repose. Choosing the best option depends on patient factors, such as age, comorbidities, and injury factors. Different materials are available for static sling surgery; we believe autologous tendon offers the most reliable and long-lasting results. Static suspension procedures provide immediate results, improved resting position, and can augment other techniques. This article discusses available options for static reanimations to address the eye complex, midface, and mouth.
Background:
Reconstruction of orbit-sparing palatomaxillary defects requires consideration of globe dystopia, orbital volume, eyelid position and function, and the nasolacrimal system to preserve and optimize vision, globe protection, and appearance. We describe the fundamentals of orbital and eyelid anatomy, common orbital complications related to palatomaxillary reconstruction, and preemptive and corrective surgical techniques to be utilized during and after globe-sparing palatomaxillary reconstruction.
Methods:
We present a review of the literature supplemented by clinical case examples.
Results:
We advocate for the use of preemptive and corrective techniques to ensure optimal aesthetic and functional outcomes for patients with orbital defects.
Conclusions:
Recognition and anticipation of problems in patients undergoing midface ablative and reconstructive procedures are vital to the implementation of corrective measures. Incision choice, orbital volume restoration, appropriate orbital floor reconstruction, and permanent or temporary lower eyelid suspension during the primary surgery can all significantly impact the development of long-term orbital complications.
An atonic reversal of the lower eyelid is of an involutionary character or occurs when the innervation of the facial nerve. When it occurs, in addition to a pronounced cosmetic defect, there is a threat of serious complications from the eyeball. The variants of treatment of atony seamy side of lower century are considered in a scientific review. An effective method of treatment is surgical correction. Various methods of surgical correction of atonic reversal of the lower eyelid were used, but there is still no single universal, optimal method. One of variants applying on universality is hanging of lower century. When the lower eyelid is suspended with synthetic materials, a long-term stable result is created. With the purpose of reduction of amount of complications the modified reticulated implant was used. Positive data of his application are got. His further clinical study is needed.
The most devastating sequelae of the facial nerve paralysis is the loss of eye lid function. The inability to blink, lubricate and protect the globe can lead to exposure keratitis, corneal abrasion and even the loss of vision. Eyelid closure is approximately 85% upper eyelid and 15% lower eyelid. In order to ensure adequate protection of the globe, deficiencies of both eyelids must be addressed. We report our experience with 20 patients with eyelid paralysis. Upper lid reanimation was performed by the placement of gold lid weights on the tarsal plate. Lower lid reanimation procedures included lateral canthopexy and horizontal lid shortening. A discussion of the above-mentioned procedures, the timing of the procedures and a critical analysis of results will be included. A comprehensive approach to the management of the paralyzed eye will be presented.
To assess which signs and symptoms were relieved by gold weight implantation and which signs and symptoms persisted.
Prospective observational cohort.
Tertiary care neurotology and oncology center.
Sixteen (4 males and 12 females) consecutive patients whose average age was 56 years (age range, 31-76 years). Inclusion criteria were gold weight implant, lagophthalmos of 2 mm or more, and a House-Brackmann score of 3 or less at the completion of follow-up. Mean follow-up was 13 months.
Each patient received a gold weight implant. Six of these patients underwent a lower eyelid procedure.
Surgical complications, static and dynamic lagophthalmos, static and dynamic corneal coverage, visual acuity, keratitis, topical treatment, and patient satisfaction.
There were no extrusions. The preoperative mean lagophthalmos was 7.5 mm and the postoperative mean was 0.5 mm, (P<.001). Corneal coverage with eye closure before implantation was 73% and after implantation was 100%, (P<.001). Corneal coverage with normal (reflex) blink was less than 50% in 9 of 14 patients. When wearing correction, no patients had 20/20 visual acuity. The mean patient satisfaction score before the procedure was 3.5 and after was 7.1, (P<.001). Patient satisfaction was most closely related to visual acuity. The relationship was linear and statistically significant (P<.04).
Gold weight implantation provides significant reduction in lagophthalmos and significant improvement in corneal coverage. But owing to delayed closure time and disrupted tear film, irritation may persist. As a result, some patients require ongoing topical treatment of the eye, which can compromise visual acuity.
Background: Although they are traditionally reserved for "aesthetic refinement" in the latter stages of facial reanimation surgery, the author uses a variety of autogeneous fascia lata grafts in a very aggressive approach as the primary therapeutic option in static facial rebalancing and/or in conjunction with dynamic muscle transfers to achieve architectural integrity and functional restoration of the totally or partially paralyzed face. Methods: Forty-nine autogeneous fascia lata grafts, harvested through serial incisions in the lateral thigh, were placed in 35 totally or partially paralyzed faces. The grafts were categorized by anatomical location: I and II, lateral lip in totally paralyzed and partially paralyzed faces, respectively; III, nostril suspension; IV, lower eyelid suspension; V, bimalar lower lip sling; and VI, platysma transfer/autogeneous fascia lata extension for lower lip invagination. Results: In all group I and II cases, static balance of facial architecture was restored at 4 to 6 weeks (after swelling resolved). Average lip commissure displacement was corrected to within 0.5 cm of the horizontal axis. Subjective functional improvement in speech, fluid retentions, and chewing was immediate in all cases. In group I (n = 10; median age, 10.5 years), a 60 to 100 percent symmetrical smile was achieved with voluntary gracilis contraction of 3 of 5 to 5 of 5. In group II (n = 20; median age, 33 years), with 16 sling only patients, one to two grades of voluntary risorius and lip elevator motion were achieved in most. When accompanied by a temporalis turnover flap, both risorius and lip elevator function improved two to three grades. In group III (n = 5), inspiratory collapse was ameliorated in all cases and nasal flow improved subjectively 80 to 100 percent. In group IV (n = 4), scleral show and keratitis were improved in all cases. In group V (n = 6), improved oral competence was achieved in all patients. In group VI (n = 4), static lip evagination was achieved in all cases; voluntary lip depressor function was two to four grades improved. Conclusions: Early placement of autogenous fascia lata restores static balance of the deeper facial architecture in repose. Functional improvement of chewing, fluid retention, speech articulation, smile symmetry, and ectropion is immediate. The psychological effect is also immediated, with achievement of self-esteem and acceptance by family and peers.
Purpose: When attempting to elevate the lower eyelid for any reason, medial elevation is the most difficult to attain. Medial canthal tendon tightening creates mostly horizontal tension and contributes little vertical vector. We present a technique for applying a lifting force to the medial end of the eyelid: medial tarsal suspension. Methods: The technique to suspend the medial lower eyelid tarsal plate to the superior orbital rim periosteum is described. The procedure, medial tarsal suspension (MTS), was performed on 38 lower lids of 24 patients. Adjunctive procedures, most commonly lateral canthal sling, were performed on 66% of the lids at the time of the initial medial tarsal suspension. The patients ranged in age from 29 years to 84 years. All had medial lower eyelid retraction, with facial nerve palsy, Graves eye disease, involutional lower eyelid retraction, and forms of muscular dystrophy the commonest etiologies. Results: Thirty-one (82%) of the 38 MTS procedures were successful. There was no unifying factor among the seven failed procedures in five lids of five patients. Three of the five patients, including two who were operated on twice, ultimately had a successful MTS. This procedure was not repeated on the other two failed patients. Range of follow-up was 9 months to 5.6 years, with a mean of 3.7 years. The mean elevation of the central lower eyelid was 1.6 mm in the successful cases. Conclusions: Medial tarsal suspension is an effective way to elevate the medial end of the lower eyelid.
A modification of the dermal-flap canthoplasty, described by Edgerton and Wolfort for the correction of paralysis of the lower lid, is described. It has produced excellent results in our experience.
All patients with a VIIth nerve paralysis with any limitation of closure of the eye should have in the office or out-patient clinic setting: 1. paper tarsorrhaphy of the upper or possibly lower lid; 2. artificial tears and/or ointment; and 3. glasses to protect the cornea from air currents
Kinetic and static surgical procedures are discussed. The kinetic procedures include facial nerve repair and grafting, VIIth-XIIth nerve anastamosis, muscle nerve block transplantation, transposition of nonparalyzed muscle and cross over. The principals of VIIth nerve repair and grafting are presented in the intracranial, internal auditory canal, labyrinthine, tympanomastoid and extratemporal sites. The static procedures include resection of redundant skin, fascia lata strip suspension, weakening of contralateral non-paralyzed musculature, and adjunctive procedures such as resection of ptotic melolabial fold, plication of parotid-masseteric fascia, dermal graft suspension, blepharoplasty, brow lift, canthoplasty, horizontal shortening of lower lid, fascial suspension of lower lip, McLaughlin tarsorrhaphy, and palpebral spring. Patient counseling is emphasized.
The medial canthal tendon and the fragment of bone on which it inserts ("central" fragment) are the critical factors in the diagnosis and treatment of nasoethmoid orbital fractures. The status of the tendon, the tendon-bearing bone segment, and the fracture pattern define a clinically useful classification system. Three patterns of fracture are appreciated: type I--single-segment central fragment; type II--comminuted central fragment with fractures remaining external to the medial canthal tendon insertion; and type III--comminuted central fragment with fractures extending into bone bearing the canthal insertion. Injuries are further classified as unilateral and bilateral and by their extension into other anatomic areas. The fracture pattern determines exposure and fixation. Inferior approaches alone are advised for unilateral single-segment injuries that are nondisplaced superiorly. Superior and inferior approaches are required for displaced unilateral single-segment injuries, for bilateral single-segment injuries, and for all comminuted fractures. Complete interfragment wiring of all segments is stabilized by junctional rigid fixation. All comminuted fractures require transnasal wiring of the bones of the medial orbital rim (medial canthal tendon-bearing or "central" bone fragment). If the fracture does not extend through the canthal insertion, the canthus should not be detached to accomplish the reduction.
The success of a procedure to reanimate paralyzed eyelids is determined by the functional and cosmetic results. When the cornea is covered during blinking and sleeping, function has been restored, while a pleasing cosmetic result has been achieved if the eyes appear symmetrical when the lids are open. Several procedures have been developed to restore closure of the paralyzed upper eyelid (implantation of gold weights or open wire springs) or to correct lower lid lagophthalmos and ectropion (lower lid tightening with a Bick procedure or insertion of a closed eyelid spring). In some cases, even a combination of the Bick procedure and insertion of a spring may be insufficient to correct lower lid droop; therefore, we developed a technique to place cartilage into the lower eyelid to correct lid droop. The procedure, suggested by one of us (D.B.S.), has been performed on 51 patients to date. This article reviews our experience with these 51 consecutive patients.
The insertion of autogenous fascia lata to suspend the paralyzed cheek and lips remains one of the most widely practiced procedures in correction of long term paralysis of the lower facial muscles. For 34 months we used thin layers (1 mm) of expanded polytetrafluoroethylene (E-PTFE Gore-Tex Soft Tissue Patch) to replace autogenous fascia lata, in 20 patients, with satisfactory results. 13 patients were treated by classical techniques of insertion-suspensions of the paralyzed side with a perioral loop and slings of PTFE suspended to the zygomatic arch and the infraorbital rim, by way of nasolabial angle or rhytidectomy incisions. In 7 patients, an eyelid suspension was performed with PTFE by Arion's technique, but by replacing the classical silicon thread by E-PTFE and transposing the medial part of the temporalis muscle on the external canthus, and fixing the lateral end of the sling to the muscle. This technique assures a good corneal coverage with healing of the previous ulceration and allows a voluntary occlusion of the eyelids. The PTFE soft tissue is notably successful as an implant. This biocompatible material shows excellent tissue tolerance, the porous microstructure encouraging tissue attachment and infiltration. E-PTFE holds its shape, resists to infection, and permits a notably reduction of the hospitalization because it avoids a second surgical site. We have experience of the material as a reconstructive substance in 6 cases of either bone or subcutaneous deficits, where no other satisfactory solution was available. Is these cases our follow-up is 18 months.
Paralytic ectropion can be corrected with numerous procedures. Advocates of particular procedures have previously been unable to quote statistical rates of success for each procedure over significant lengths of time. This study reviews over 200 cases of paralytic ectropion, representing the spectrum of seventh nerve disease seen at an eye and ear specialty hospital and a general medical facility. Of all eyelid implantation devices 93 to 95% failed to work or needed reoperation by 3 years postoperatively. Soft tissue surgery without prosthetic implants or exoplants provided 60% success after a 3-year follow-up. Eyelid elevation or tightening coupled with surgery for facial reanimation produced a higher rate of success at 3 years (83%). An overwhelming number of patients (62%) complained of some degree of epiphora after any or all procedures. Based on these findings, soft tissue surgery without prosthetic implants or exoplants has a higher rate of success.
To determine guidelines for the management of paralyzed eyelids following facial palsy, including surgical indications, timing, and type of procedure(s).
Prospective analysis of 60 patients diagnosed as having complete facial palsy. Follow-up ranged from 18 to 36 months.
All subjects had a complete unilateral facial palsy of various origins. Ages ranged from 6 to 81 years.
Forty patients underwent evoked electromyography and blink reflex testing of the facial nerve. Twenty additional patients had a known fifth-degree nerve injury that did not require testing.
Lack of interval improvement in clinical results of examination and/or evoked electromyography, coupled with length of time from injury, were used to determine surgical candidacy. All patients with fifth-degree nerve injury were considered surgical candidates, with clinical examination results of eyelid function used to determine which procedure(s) to be performed.
Of the 60 patients evaluated with facial palsy, 43 patients required surgical restoration of eyelid function. Forty-one patients required gold weight implants; 18 of these also required shortening of the lower eyelid. Two additional patients underwent eyelid shortening without gold weight implantation. Seventeen patients were treated only with corneal lubricants and moisturizers. No gold weights extruded; there were no infections. Two patients required revision of their lower eyelid surgery owing to progressive laxity. Four patients have had their gold weights removed an average of 9.5 months following insertion.
The degree of neural injury and its associated regeneration time, determined clinically and by evoked electromyography, are useful factors to assist in patient selection, surgical timing, and type of procedure(s) necessary to fully rehabilitate the upper and lower eyelids following facial paralysis.
Traditional methods of paralytic ectropion repair fail to elevate the medial lower lid and inferior punctum into the proper position. That deficiency does not exist with relatively simple, time-proven technique we have described. A lazy trapezoidal-shaped cartilage graft attached to a fascial sling restored the lost tone and medial lid posture, thrusting the punctum back into its normal and properly functioning position. The operation takes its name from Diamond Head crater in Waikiki, Hawaii, whose silhouette resembles the required cartilage graft responsible for the correction.
The most devastating sequelae of the facial nerve paralysis is the loss of eyelid function. The inability to blink, lubricate and protect the globe can lead to exposure keratitis, corneal abrasion and even the loss of vision. Eyelid closure is approximately 85% upper eyelid and 15% lower eyelid. In order to ensure adequate protection of the globe, deficiencies of both eyelids must be addressed. We report our experience with 20 patients with eyelid paralysis. Upper lid reanimation was performed by the placement of gold lid weights on the tarsal plate. Lower lid reanimation procedures included lateral canthopexy and horizontal lid shortening. A discussion of the above-mentioned procedures, the timing of the procedures and a critical analysis of results will be included. A comprehensive approach to the management of the paralyzed eye will be presented.
The seventh nerve palsy causes loss of function in the affected orbicularis oculi muscle. There is exposure and dessication of the corneal surface and obvious aesthetic changes in facial symmetry.
A surgical procedure has been used in 11 patients to substantially improve palpebral closure. The technique consists of a small upper lid tarsoconjunctival flap sutured into a nasal pretarsal pocket of the lower lid, achieving a medial tarsal suspension of the lower lid.
This technique improves cosmesis, is reversible, and combinable with other procedures. The signs and symptoms of exposure keratitis are satisfactorily resolved. There have been no complications in an average follow up of 5 1/2 years after this surgical procedure.
This technique could be considered an appropriate treatment for patients suffering temporary or permanent facial palsy.
Blindness is the most dreaded complication of an untreated paralyzed eyelid following injury to the facial nerve. Injuries to the facial nerve are mainly postsurgical. Assessment of neural injury using serial testing is important to be able to differentiate between temporary and permanent paralysis. In the former case, medical management could be sufficient and, in the latter case, a surgical procedure is required. The physician has the choice among several procedures to repair upper eyelid paralysis with the gold standard being the gold weight implant. Lower eyelid ectropion can be repaired using a lateral or medial canthal tightening procedure. If the lower eyelid ectropion is severe, a cartilage implant may be required.
When attempting to elevate the lower eyelid for any reason, medial elevation is the most difficult to attain. Medial canthal tendon tightening creates mostly horizontal tension and contributes little vertical vector. We present a technique for applying a lifting force to the medial end of the eyelid: medial tarsal suspension.
The technique to suspend the medial lower eyelid tarsal plate to the superior orbital rim periosteum is described. The procedure, medial tarsal suspension (MTS), was performed on 38 lower lids of 24 patients. Adjunctive procedures, most commonly lateral canthal sling, were performed on 66% of the lids at the time of the initial medial tarsal suspension. The patients ranged in age from 29 years to 84 years. All had medial lower eyelid retraction, with facial nerve palsy, Graves eye disease, involutional lower eyelid retraction, and forms of muscular dystrophy the commonest etiologies.
Thirty-one (82%) of the 38 MTS procedures were successful. There was no unifying factor among the seven failed procedures in five lids of five patients. Three of the five patients, including two who were operated on twice, ultimately had a successful MTS. This procedure was not repeated on the other two failed patients. Range of follow-up was 9 months to 5.6 years, with a mean of 3.7 years. The mean elevation of the central lower eyelid was 1.6 mm in the successful cases.
Medial tarsal suspension is an effective way to elevate the medial end of the lower eyelid.
Trauma to the central midface may result in complex nasoethmoid orbital fractures. Due to the intricate anatomy of the region, these challenging fractures may often be misdiagnosed or inadequately treated. The purpose of this article is to aid in determining the appropriate exposure and method of fixation.
This article presents an organized approach to the management of nasoethmoid orbital fractures that emphasizes early diagnosis and identifies the extent and type of fracture pattern. It reviews the anatomy and diagnostic procedures and presents a classification system. The diagnosis of a nasoethmoid orbital fracture is confirmed by physical examination and CT scans. Fractures without any movement on examination or displacement of the NOE complex on the CT scan do not require surgical repair. Four clinical cases serve to illustrate the surgical management of nasoethmoid fractures.
Early treatment using aggressive techniques of craniofacial surgery, including reduction of the soft tissue in the medial canthal area and restoration of normal nasal contour, will optimize results and minimize the late post-traumatic deformity. A high index of suspicion in all patients with midfacial trauma avoids delays in diagnosis.
We have developed an alternative technique for the correction of ectropion in facial paralysis using a precise anchor suture. The anchor, with 3-0 nonabsorbable suture attached, is inserted into a hole at the frontal process of the maxilla. The sutures are passed from a medial canthal incision in the submuscular and pre-tarsal plane through stab incisions in sequence to a lateral canthal incision and then tied to the periosteum of the frontal process of the zygoma to keep the lower eyelid in a slightly overcorrected position. Our experience over a mean follow-up period of 24 months has shown this simple and fast procedure to be a safe and reliable option for ectropion caused by facial paralysis.
Although they are traditionally reserved for "aesthetic refinement" in the latter stages of facial reanimation surgery, the author uses a variety of autogenous fascia lata grafts in a very aggressive approach as the primary therapeutic option in static facial rebalancing and/or in conjunction with dynamic muscle transfers to achieve architectural integrity and functional restoration of the totally or partially paralyzed face.
Forty-nine autogenous fascia lata grafts, harvested through serial incisions in the lateral thigh, were placed in 35 totally or partially paralyzed faces. The grafts were categorized by anatomical location: I and II, lateral lip in totally paralyzed and partially paralyzed faces, respectively; III, nostril suspension; IV, lower eyelid suspension; V, bimalar lower lip sling; and VI, platysma transfer/autogenous fascia lata extension for lower lip invagination.
In all group I and II cases, static balance of facial architecture was restored at 4 to 6 weeks (after swelling resolved). Average lip commissure displacement was corrected to within 0.5 cm of the horizontal axis. Subjective functional improvement in speech, fluid retention, and chewing was immediate in all cases. In group I (n = 10; median age, 10.5 years), a 60 to 100 percent symmetrical smile was achieved with voluntary gracilis contraction of 3 of 5 to 5 of 5. In group II (n = 20; median age, 33 years), with 16 sling only patients, one to two grades of voluntary risorius and lip elevator motion were achieved in most. When accompanied by a temporalis turnover flap, both risorius and lip elevator function improved two to three grades. In group III (n = 5), inspiratory collapse was ameliorated in all cases and nasal flow improved subjectively 80 to 100 percent. In group IV (n = 4), scleral show and keratitis were improved in all cases. In group V (n = 6), improved oral competence was achieved in all patients. In group VI (n = 4), static lip evagination was achieved in all cases; voluntary lip depressor function was two to four grades improved.
Early placement of autogenous fascia lata restores static balance of the deeper facial architecture in repose. Functional improvement of chewing, fluid retention, speech articulation, smile symmetry, and ectropion is immediate. The psychological effect is also immediate, with achievement of self-esteem and acceptance by family and peers.
To describe a new 3-dimensional technique for medial canthal repositioning, precaruncular medial canthopexy (PMC), and to present an outcome study demonstrating its efficacy.
Data (age, sex, cause, and initial symptoms) were collected prospectively on patients with malposition of the lower eyelid. All patients were photographed before and after surgery in a set protocol. The type and severity of eyelid malposition were documented using the Ectropion Grading Scale (EGS) before and after each procedure. Surgical outcome was evaluated by objective improvement of ectropion grading and subjective resolution of symptoms.
Precaruncular medial canthopexy was performed on 30 eyelids of 27 consecutive patients (10 were revisions) for correction of medial eyelid laxity or malposition. Twenty-six patients had ectropion, and 1 had bilateral entropion. The most common cause of eyelid malposition was facial paralysis (n = 21). Ancillary procedures, most commonly lateral transorbital canthopexy (for correction of lateral ectropion), were performed on 60% of the eyelids at the time of PMC. Twenty-eight procedures resulted in complete restoration of the medial canthus to a normal position (EGS grade I). Two patients had minimal residual medial scleral show after surgery (EGS grade II) but experienced symptom relief. There were no wound infections or perioperative complications.
Precaruncular medial canthopexy rapidly and safely restores support in all 3 dimensions without blocking the visual field or damaging the lacrimal system, with minimal morbidity and excellent wound healing. In addition to being a primary technique for correcting medial eyelid malposition, PMC should be routinely considered as an adjunct procedure when correcting lateral eyelid malposition.
Paralysis of the upper part of the face results in both loss of function and cosmesis of the eyelids. While much has been discussed concerning the upper lid, assessment of the lower lid has often been nonspecific. The dysfunctional lower lid can be classified into medial and lateral problems. Medial canthal laxity results in retraction of the inferior punctum away from the globe in a lateral, anterior, and inferior position. The interruption of the passive lacrimal drainage system, in combination with the ablation of the lacrimal pump provided by the orbicular muscle of the eye, results in epiphora. Lateral canthal laxity produces scleral show and, when severe, ectropion. These features contribute to the failure of the lower lid to approximate the upper lid even when the upper lid has been fully rehabilitated. A margin gap of the lid aperture can ultimately lead to corneal keratitis and deterioration of vision. Rehabilitation of the lower lid is dependent on accurate assessment of the presenting anatomical deformities and their correction. In a series of nine patients, these deformities have been addressed. To correct medial canthal laxity and to reestablish contact of the inferior punctum to the globe, support has been provided with static slings. Polytef (Gore-Tex), which is nonelastic, has proved to be an excellent static sling material. To correct lateral canthal laxity resulting in scleral show and ectropion, lateral lid shortening procedures were performed. These procedures, in conjunction with upper lid rehabilitation, have been successful in providing better function and cosmesis to the paralyzed eye.
(Arch Otolaryngol Head Neck Surg. 1993;119:1338-1344)
Blunt trauma to the midface frequently results in fractures of the nasoethmoid orbital skeleton. These complex injuries are often misdiagnosed or inadequately treated and are perhaps the most difficult of all facial fractures to treat. The purpose of this article is to describe the author's technique for the diagnosis and treatment of these complex fractures. Presented is an organized approach to the diagnosis and surgical management of nasoethmoid orbital fractures that has evolved in the author's treatment of over 450 nasoethmoid fractures. Early diagnosis is confirmed by computed tomographic scan using the simple classification system described. Fractures that demonstrate displacement or movement on examination require open reduction and stabilization. Identifying the extent and type of fracture pattern and associated injuries determines the exposure and method of fixation needed. Wide exposure with meticulous reduction is necessary, with stabilization of the medial orbital rim fragment using a transnasal wire technique. Plate-and-screw fixation of the superior and inferior rim is performed with bone graft reconstruction of the nose as needed. Attention to redraping of soft tissue in the naso-orbital valley with the use of nasal compression bolsters is a crucial step in the repair. Multiple clinical cases are used to illustrate the different fracture patterns, soft-tissue injuries, and surgical technique recommended. This organized approach has proven effective in restoring preinjury appearance. Early diagnosis combined with the aggressive surgical techniques described will optimize results and minimize the late posttraumatic deformity.
: Restoration of eyelid animation and aesthetics is a major component of the surgical management of facial paralysis. The authors' experience with the minitendon graft (a piece of split palmaris tendon graft) for lower eyelid suspension is presented. The effect of age, cause, denervation time, and total number of procedures performed in the eye region are analyzed.
: Fifty-eight patients with facial paralysis presenting with paralytic ectropion received the minitendon graft for lower eyelid suspension. Twenty-eight patients with concurrent lagophthalmos received the eye spring (n = 14) or gold weight (n = 14). Scleral show and lagophthalmos were measured by the same investigator (S.A.K.) using the methodology established by Terzis and Bruno. Outcomes were graded as follows: grade 1, no change; grade 2, minimal change; grade 3, moderate change; grade 4, good (more than half decrease); and grade 5, excellent, no scleral show or lagophthalmos.
: Seventy percent of the patients were female, and in 40 percent the cause was developmental. There was clear improvement in both scleral show and lagophthalmos (p < 0.001). More than 80 percent of the outcomes were graded as good to excellent for both scleral show and lagophthalmos. There was correlation between age and cause, but neither affected outcomes. Denervation time had no influence on the results (p = 0.942).
: The minitendon graft for lower eyelid suspension is an effective technique for repositioning the paralyzed lower eyelid regardless of patient age, denervation time, or cause of injury, and may be effectively combined with the eye spring or gold weight in the presence of lagophthalmos.