Surgical treatment of lagophthalmos in facial palsy: ear cartilage graft for elongating the levator palpebrae muscle

Auricular Cartilage Graft for Lengthening Levator Muscle Aponeurosis With Ectropion Correction for Paralytic Lagophthalmos

BACKGROUND

Paralytic lagophthalmos can have devastating consequences for vision if left untreated. Several surgical techniques have been described, including the utilization of alloplastic and autologous materials.

OBJECTIVES

The authors sought to evaluate the effectiveness of the surgical treatment of paralytic lagophthalmos with combined techniques employing autologous material and involving the upper and lower eyelids.

METHODS

Patients with paralytic lagophthalmos underwent stretching of the levator aponeurosis with interposition of conchal cartilage in the upper eyelid associated with sectioning of the orbitomalar ligament and lateral canthoplasty in the lower eyelid. The effectiveness of the technique was evaluated employing subjective (symptomatology) and objective parameters (ophthalmologic evaluation and measurements of lagophthalmos and marginal reflex distances 1 and 2).

RESULTS

Eight patients with paralytic lagophthalmos were subjected to the proposed technique. In the postoperative period, 85.7% reported complete improvement of symptoms and 62.5% presented a normal eye examination. The mean lagophthalmos measurement was reduced by 5.93 mm, the mean marginal reflex distance 2 was reduced by 2.61 mm, and the mean marginal reflex distance 1 was reduced by 0.69 mm.

CONCLUSIONS

The technique presented herein, employing autologous material associated with sectioning of the orbitomalar ligament and lateral canthoplasty, was effective in the treatment of paralytic lagophthalmos and did not present significant complications, such as extrusion.

LEVEL OF EVIDENCE: 4

Septal chondromucosal grafts in paralytic lagophthalmos

OBJECTIVE

The risk of sight-threatening complications related to facial paralysis makes palpebral fissure management a priority. Surgery must take account of and adapt to the clinical signs of paralytic lagophthalmos. This therefore presupposes that a sufficient therapeutic arsenal is available. In this report, we propose a technique for palpebral lengthening (lower and/or upper), reconstructing the posterior lamella using a chondromucosal graft harvested from the nasal septum, combined with anterior lamellar repositioning.

PATIENTS AND METHOD

A 5-year single center retrospective study was conducted, including sixteen patients for a total of nineteen septal chondromucosal grafts. The only inclusion criterion was paralytic lagophthalmos. Functional ophthalmic deficits were recorded (main outcome measure), first preoperatively, then postoperatively. Additionally, the degree of lagophthalmos was measured in order to infer palpebral fissure elongation gain. Surgical consequences and complications were recorded.

RESULTS

A rapid regression in functional ophthalmic deficits was observed in 87% of patients, improving in stability over time (mean follow-up interval of 34 months). Mean palpebral fissure elongation gain was 3 mm. 53% of patients suffered from complete occlusion of the palpebral fissure. Surgical consequences were uncomplicated. 38% of patients eventually underwent revision surgery.

CONCLUSION

Palpebral fissure lengthening using septal chondromucosal grafts serves as an alternative to existing treatment methods for paralytic lagophthalmos. Robust functional and cosmetic results, combined with very low morbidity, make this a simple and efficient technique whose indications may be extended.

[Management of oculo-palpebral consequences in facial paralysis]

Facial paralysis prognostic depends on eye lesion. In this pathology, lacrymal and palpebral functions will be modified: bad eye closure and leak of tears secretions. It can leads to corneal complications from keratitis to corneal abcedation and visual dysfonction. This chapter details different procedures and their indications to avoid this kind of complications.

Treatment of migration and extrusion of the gold weight eyelid implant with fascia lata sandwich graft technique

Gold weight implantation is generally considered a safe procedure for the treatment of paralytic lagophthalmos. The most frequently seen complications are extrusion, malpositioning, and migration of the implant. To decrease the rate of these complications, several modifications were defined in the composition and the shape of the implant as well as the surgical technique itself. Despite these precautions, implant revision rates are still as high as 8% to 14%. Nowadays, implant-covering or implant-wrapping procedures are becoming more popular to avoid implant-related problems. However, there is limited information in the literature regarding the management of these complications. In this study, we aimed to present the treatment of migration and extrusion of the gold weight implant in a patient with Moebius syndrome by wrapping the implant with autogenous fascia lata graft.

Static treatment of paralytic lagophthalmos with autogenous tissues

BACKGROUND

Long-standing facial paralysis is frequently seen in patients who have undergone surgical procedures with sacrifice of the facial nerve and have never been counseled about limiting its consequences. Lagophthalmos must always be treated in these patients to protect vision. The authors describe their techniques of static treatment for lagophthalmos using autologous tissues and their classification system for standardizing patients.

METHODS

From July 2001 to September 2005, 12 patients (9 men and 2 women) ranging in age from 37 to 77 years (mean, 58.5 years) were treated. Their paralysis was attributable to acoustic neuroma resection in seven cases, to resection of a cerebral vascular anomaly in two cases, and to total parotidectomy with facial nerve sacrifice in three cases. The patients were treated with elongation of the levator palpebrae superioris muscle using a fascia lata graft, bolstering of the lower eyelid with a conchal cartilage graft, or both, combined with a Kuhnt type resection when needed.

RESULTS

Complete closure was achieved for nine patients (75%). For all the patients, resolution of symptoms and keratitis was achieved. No complications were observed. The follow-up period ranged from 14 to 51 months (mean, 39.5 months). The cosmetic outcome also was satisfactory.

CONCLUSIONS

For candidates eligible to undergo static treatment of lagphthalmos, the techniques described may be considered valuable options for the correction of lagophthalmos using autologous tissues, thus avoiding the complications related to alloplastic material implantation.