Eyelid reanimation with gold weight implant and tendon sling suspension: Evaluation of excursion and velocity using the FACIAL CLIMA system

Enhancing Lower Eyelid Suspension Outcomes Through Pre-surgical Facial Nerve Reanimation: A Comparative Study

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

LEVEL OF EVIDENCE IV

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 .

'Are dynamic procedures superior to static in treating the paralytic eyelid in facial paralysis?'

BACKGROUND

Facial nerve weakness can cause deficient eye closure with reduced corneal protection. Surgical remedies can be static to oppose the levator muscle (lid loading) or dynamic procedures, which act to increase the strength of closure. This retrospective cohort study compares these groups. The hypothesis is that dynamic reconstruction has advantages over static techniques in terms of eye closure, symptomatic improvement, blink restoration, and complication rate.

METHODS

Two cohorts were compared: those treated with a gold weight insertion into the upper eyelid and those who had received dynamic reconstruction. These included temporalis transfer; cross face nerve grafting alone (CFNG) and CFNG followed by free tissue transfer. Assessments included standard photography and video; measurement of eyelid excursion including residual gap and if full eye closure was possible. The presence of the blink reflex and symptoms of dry eye was assessed.

RESULTS

Overall improvement in eye closure was similar with the gold weight compared to dynamic procedures (5.1 mm vs 5.3 mm). Dynamic procedures however gave improved results in terms of symptom relief and restoration of blink. They also had fewer complications and revision rates overall.

CONCLUSION

The study confirms the hypothesis that dynamic reconstructions of the paralysed eyelid confer advantages compared to simple lid loading techniques. Improvements in lid excursion are similar, but symptom improvement and blink restoration are significantly better. A decision regarding eyelid reanimation should be made early in the patient's journey of facial reanimation to allow for accurate planning and placement of nerve grafts at an early stage.

Enhanced Ionic Polymer-Metal Composites with Nanocomposite Electrodes for Restoring Eyelid Movement of Patients with Ptosis

The present study aims to use enhanced ionic polymer-metal composites (IPMC) as an artificial muscle (a soft-active actuator) to restore eyelid movement of patients with ptosis. The previous eyelid movement mechanisms contained drawbacks, specifically in the lower eyelid. We used finite element analysis (FEA) to find the optimal mechanism among two different models (A and B). In addition to common electrodes of IPMC (gold and platinum), the bovine serum albumin (BSA) and microcrystalline cellulose (MCC) polymers, with optimal weight percentages of carbon nanotube (CNT) nanofiller, were also utilized as non-metallic electrodes to improve the efficiency of the IPMC actuator. In both models, IPMC with nanocomposite electrodes had higher efficiency as compared to the metallic electrodes. In model A, which moved eyelids indirectly, IPMC with MCC-CNT electrode generated a higher force (25.4%) and less stress (5.9 times) as compared to IPMC with BSA-CNT electrode. However, the use of model A (even with IPMCs) with nanocomposite electrodes can have limitations such as possible malposition issues in the eyelids (especially lower). IPMC with MCC-CNT nanocomposite electrode under model B, which moved eyelids directly, was the most efficient option to restore eyelid movement. It led to higher displacements and lower mechanical stress damage as compared to the BSA-CNT. This finding may provide surgeons with valuable data to open a window in the treatment of patients with ptosis.

Three-Dimensional Quantification of Facial Morphology and Movements Using a Wearable Helmet

This work proposes a 3D normative database of facial ranges of motion in adults free from facial disorders. Ten facial movements were analyzed, each targeting the activity of specific muscle groups innervated by the facial nerve. The experimental protocol included a test-retest reliability positioning procedure of 25 skin markers based on clinical expertise in facial morphology. Three maximal voluntary contractions were recorded for each facial movement studied, using a 3D facial motion capture helmet. We included 53 adults free from facial disorders (26 men; age $43\pm 14$ ), evaluated twice one week apart. The reliability of marker positioning was expressed as absolute measurement errors. The range of motion vectors of all markers from the best rest to the maximal voluntary contraction was calculated for each muscle group. Primary, secondary, and tertiary markers were extracted for each facial movement. 3D Procruste and asymmetry indices were developed. This allowed the identification of common thresholds of 10% for the asymmetry index and of 6 mm for the Procruste index, beyond which facial motions would be considered abnormally asymmetric. The normative database quantifies facial motions and allows assessment of the degree of clinical disorders by comparison. This protocol is currently being investigated in patients with chronic unilateral peripheral facial paresis.

Masseteric nerve transference with sling tendon for symmetry in the restoration of facial paralysis: An effective combination of dynamic and static correction

Masseteric nerve transposition has shown to be an effective technique for the treatment of facial paralysis. Due to its low morbidity at the donor site, its consistent anatomy, and one-stage operation, it constitutes a reliable option for both complete and incomplete facial paralysis. Masseteric nerve transference has proven to achieve good commissural excursion and dynamic symmetry. However, some patients with heavy faces and complete facial paralysis recover incompletely after surgery characterized by an asymmetrical smile with asymmetry at rest, affecting the cosmetic appearance. For these patients, we propose a novel combination of masseteric nerve transposition for the dynamic rehabilitation of the smile with a tendon sling suspension to create symmetry at rest. A detailed description of the surgical technique is given and results after using it with eight patients show good functional and aesthetic satisfaction. A combination of both dynamic and static techniques for complete facial paralysis rehabilitation may provide adequate symmetry with the contralateral healthy side both at rest and when smiling.

Maximizing the Smile Symmetry in Facial Paralysis Reconstruction: An Algorithm Based on Twenty Years' Experience

Over the last two decades, the senior author (B.H.) has had an extensive experience with facial paralysis reconstruction. During this period, the techniques have evolved substantially based on the experience and after observing and analyzing the surgical outcomes. The purpose of this article is to relay the lessons learned from the 20 years' experience and suggest an algorithm. In this retrospective study, we have included 343 cases of facial paralysis cases. Complete facial paralysis cases were 285 and 58 were incomplete facial paralyses, both requiring surgical procedures. Complete facial paralyses were divided in to short term (n = 83) and long term (n = 202). In total, 58% of the patients were women and 42% were men. The age range was 6 to 82 years. The techniques employed were direct suture, nerve grafts, cross-facial nerve grafts (CFNGs), masseteric-to-facial nerve transference, hypoglossal-to-facial nerve transference, free muscle transplants, and lengthening temporal myoplasty to achieve the best symmetry after reanimation of unilateral, bilateral, complete, and incomplete facial paralysis. The type of paralysis, objective measurements, the personal patient's smile, and the gender are key concepts to be considered before scheduling a dynamic facial paralysis reconstruction. For unilateral facial paralysis, the time of onset, the type of paralysis, the patient's comorbidities, and the healthy side status are some of the determining factors when selecting the correct technique. The preferred techniques for unilateral facial paralysis are direct repair, CFNG, masseteric-to-facial transposition, and free gracilis transfer. For incomplete facial paralysis, the masseteric-to-facial nerve transference is preferred. In bilateral facial paralysis, bilateral free gracilis transfer is performed in two stages using the nerve of the masseter muscle as the source of innervation. The authors provide an algorithm which simplifies facial paralysis reconstruction to achieve the greatest facial symmetry while thinking about the potential comorbidities and developing spontaneity smile according to the gender of the patient.

Augmented fascia temporalis sling for paralytic ectropion of the lower lid

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.

Lateral transorbital canthopexy using a silicone tube in patients with paralytic ectropion

PURPOSE

We describe the efficacy of lateral transorbital canthopexy using a silicone tube in managing severe paralytic ectropion.

METHODS

Patients with paralytic ectropion involving at least two-third of lower eyelid length and scleral exposure of 3 mm or more were considered. A silicone prosthetic was inserted during canthopexy.

RESULTS

Lateral transorbital canthopexy using a silicone tube was performed on 10 eyelids in nine patients. All patients had corneal surface abnormalities. Scleral exposure resolved completely in three cases. At 8-month follow-up, residual scleral exposure of 1 mm and 2 mm persisted in n = 6 and n = 1 cases, respectively.

CONCLUSIONS

Lateral transorbital canthopexy using a silicone tube is an effective therapeutic option for paralytic ectropion, facilitating both functional and cosmetic results that proved durable over time.

Specific Refractory Gold Flotation and Bio-Oxidation Products: Research Overview

This paper presents a research overview, reconciling key and useful case study findings, towards uncovering major causes of gold refractoriness and maximising extraction performance of specific gold flotation and bio-oxidation products. Through systematic investigation of the ore mineralogical and gold deportment properties, leaching mechanisms, and kinetic behaviour and pulp rheology, it was observed that the predominant cause of the poor extraction efficacy of one bio-oxidised product is the presence of recalcitrant sulphate minerals (e.g., jarosite and gypsum) produced during the oxidation process. This was followed by carbonaceous matter and other gangue minerals such as muscovite, quartz, and rutile. The underpining leaching mechanism and kinetics coupled with the pulp rheology were influenced by the feed mineralogy/chemistry, time, agitation/shear rate, interfacial chemistry, pH modifier type, and mechano-chemical activation. For instance, surface exposure of otherwise unavailable gold particles by mechano-chemical activation enhanced the gold leaching rate and yield. This work reflect the remarkable impact of subtle deposit feature changes on extraction performance.

Lipofilling of the upper eyelid to treat paralytic lagophthalmos

Lagophthalmos is one of the most unpleasant and dangerous conditions that affect patients with facial palsy. The lack of ocular protection leads to corneal problems (such as conjunctival infections, acute and chronic keratitis, corneal ulcerations, and blindness). A dynamic reanimation of blinking eyelids is the therapeutic gold standard. However, success is not guaranteed with these dynamic techniques; even if results are good, blinking is usually restored within a year of the initial operation. Procedures that act more rapidly and have a higher success rate are needed. We proposed that lipofilling of the upper eyelid would improve eye closure, exploit the advantages of using autologous fat, and avoid the risks of exposure or migration associated with loading the lid with gold. Between 2012 and September 2018, we did upper eyelid lipofilling procedures for 75 patients with unilateral facial palsy. The main favourable result of lipofilling of the upper lid was the immediate improvement in corneal discomfort. Everybody described a partial to total increase in corneal comfort postoperatively. In the treatment of paralytic lagophthalmos, lipofilling of the upper eyelid produces favourable aesthetic and functional results, ocular health is restored, and the patients' quality of life is improved.

Quantitative Analysis of Paralyzed Lower Eyelid Elevation Technique: Suspension Sling versus Supporting Midcheek Lift

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.

[Rehabilitation of facial palsy and vertigo in patients with vestibular schwannoma]

BACKGROUND

Facial palsy and vertigo, as symptoms of vestibular schwannoma (VS) or consequences of its therapy, have a significant impact on patients' quality of life.

OBJECTIVE

This review analyzed current literature on the topic and deduced recommendations for rehabilitation of facial palsy and vertigo.

METHODS

The present review describes a PubMed-based search of the literature of the past 10 years.

RESULTS

There is no evidence-based drug therapy for the treatment of acute facial palsy after VS surgery. Several surgical procedures for facial nerve reconstruction, muscle transfer, and static techniques have been established. Physiotherapeutic movement therapy, optimally with biofeedback, seems to improve facial function in patients with post-paralytic syndrome. Botulinum toxin injections are the method of choice for synkinesis treatment. For treatment of acute and chronic vertigo in patients with VS, the same antivertiginous drugs as for other vertigo patients are used. If the patient shows retained vestibular stimulation function, preoperative intratympanic gentamycin therapy followed by compensation training is a promising approach to decreasing postoperative vertigo. Good vestibular rehabilitation comprises intensive and regular movement training, preferably with real-time feedback and therapy control.

CONCLUSION

There are several conservative, surgical, or combined conservative-surgical treatment options for individualized facial nerve rehabilitation of VS patients, as confirmed by clinical studies. In cases of acute vertigo, standard antivertiginous pharmacotherapy is indicated. In cases of acute and also of chronic vertigo, intensive balance and movement training relieves complaints.

Treatment of the Periocular Complex in Paralytic Lagophthalmos

Objectives:

Paralytic lagophthalmos can lead to devastating exposure keratitis. The main surgical intervention consists of upper eyelid loading. However, adjunctive lower eyelid and brow procedures are also available as necessary. We sought to analyze the use of periocular procedures in paralytic lagophthalmos at Johns Hopkins.

Methods:

The method was a retrospective review of patients treated at a single tertiary care center from 2006 to 2012.

Results:

One hundred one patients met inclusion criteria, and 20 patients were excluded for not meeting the minimum follow-up. Upper eyelid loading was required on 95/101 patients (95%). Adjunctive procedures were necessary in 73% (73/101) of patients. Lower eyelid procedures were used in 47% (47/101) and brow lifts in 47% (47/101). Older patients (>50 years) were more likely to require lower eyelid procedures ( P = .04) and more likely to require revision ( P = .003). Medial canthopexy and direct brow lift were associated with the need for revision ( P = .006, P = .03).

Conclusion:

Paralytic lagophthalmos management is not one-size-fits-all. Upper eyelid loading is the mainstay of treatment; however, adjunctive procedures to the lower eyelid and brow are indicated in the majority of patients. Our retrospective review has allowed us to continue to refine our strategy for managing these patients.

Cross-face neurotized platysmal muscular graft for upper eyelid reanimation: an anatomic feasibility study

BACKGROUND

Upper eyelid reanimation is one of the most important aspects of facial paralysis. The ideal method would be one that provided dynamic restoration of voluntary eye closure, involuntary blinking, and corneal reflex. Innervation to the platysma has shown to be relatively consistent, which would allow its use as a muscle graft neurotized by the contralateral healthy facial nerve for eyelid reanimation.

METHODS

Six fresh cadavers, 12 sides, were studied by dissecting the main trunk of the facial nerve and its cervicofacial division. Special attention was paid at the emergence of cervical branches to the platysma and its distribution on the undersurface of the muscle as well as its relationships with regional anatomic references.

RESULTS

One major branch with 1 or 2 accessory branches was found to emerge from the cervicofacial division, 1.5 cm distal to its origin in the facial nerve trunk. The major branch showed an oblique course, starting approximately 1 cm below the angle of the mandible and coursing toward the inferomedial border of the muscle. Harvest of a 3 × 2 muscle piece with a 10-cm-long neural pedicle was possible in all specimens. When presented over the superior eyelid, the nerve branch was found to reach the contralateral frontal branch of the facial nerve.

CONCLUSIONS

Innervation to the platysma muscle is relatively constant and consists of 1 major branch accompanied by 1 or 2 accessory branches. Harvest of a muscle flap with a neural pedicle long enough to reach the contralateral healthy side is anatomically feasible.