Early versus late gold weight implantation for rehabilitation of the paralyzed eyelid

Periocular management in recent facial palsy patients treated with triple innervation technique: A retrospective case series

Facial paralysis decreases eye protection mechanisms leading to ocular problems up to corneal ulceration, and blindness. This study aimed to evaluate the outcomes of periocular procedures for recent facial paralysis. Medical records of patients with unilateral recent complete facial palsy who did periocular procedures at the Maxillofacial Surgery Department of San Paolo Hospital (Milan, Italy) between April 2018 and November 2021 were retrospectively reviewed. 26 patients were included. All patients were evaluated 4 months after surgery. The first group included 9 patients who underwent upper eye lid lipofilling and midface suspension with fascia lata graft; they had no ocular dryness symptoms and no need for eye protection measures in 33.3% of cases, significant reduction of ocular symptoms and need for eye protection measures in 66.6% of patient, 0-2 mm lagophthalmos in 66.6% and 3-4 mm lagophthalmos in 33.3%. The second group of 17 patients who underwent upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy, had no ocular dryness symptoms and no need for eye protection measures in 17.6% of patient, significant reduction of ocular symptoms and need for eye protection measures in 76.4% of patient, 0-2 mm lagophthalmos in 70.5%, 3-4 mm lagophthalmos in 23.5% and one patient 5,8%had 8 mm lagophthalmos and persistent symptoms. No ocular complication, cosmetic complain or donner site morbidity were reported. Upper eyelid lipofilling, midface suspension with fascia lata graft and lateral tarsorrhaphy decrease ocular dryness symptoms and need for eye protection measures and improve lagophthalmos: the association of the reinnervation with these complementary techniques is therefore highly recommended in order to immediately protect the eye.

Sutureless transconjunctival insertion of eyelid gold weight

OBJECTIVE

Surgical intervention for paralytic lagophthalmos has been gold weight implant through supratarsal crease incision for decades. The aim of this study is to propose a modified novel minimally invasive approach that can be described as sutureless and transconjunctival placement of eyelid weights.

METHOD

Unilateral eyelid gold weights were implanted in six patients due to paralytic lagophthalmos secondary to peripheral facial nerve palsy. The patients were followed for an average of 6 months.

RESULTS

Functional and aesthetically desired results were obtained in all six patients with suture-free transconjunctival placement of the eyelid weight. The patients did not experience any discomfort and avoided the burden of suture removal after the surgery. No complications developed in six patients during the postoperative period.

CONCLUSION

Sutureless transconjunctival insertion of eyelid weight without external incision and suturing is practical, relatively easy and fast to perform. It preserves attachment of the levator muscle to the tarsus and presents functional results similar to conventional method. Fixing the implant with sutures to the tarsal plate is not needed. Sutureless of this method avoids external wound care, burden of suture removal for both surgeons and patients, and hence, suture related complications are eliminated.

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.

Analysis of Facial Reanimation Procedures Performed Concurrently With Total Parotidectomy and Facial Nerve Sacrifice

Importance

Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes.

Objective

To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database.

Design, Setting, and Participants

This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018.

Main Outcomes and Measures

Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures.

Results

Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003).

Conclusions and Relevance

In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population.

Level of Evidence

NA.

Treatment for ophthalmic paralysis: functional and aesthetic optimization

Facial nerve palsy has an effect on a person's well-being functionally and psychologically. Therefore, comprehensive patient management is essential. One of the most common uncomfortable and potentially debilitating features is associated with the incapacity for eye closure. Restoration of eye closure is a key consideration during the surgical management of facial palsy. In this article, we introduce simple surgical methods-which are relatively easy to learn and involve the upper and lower eyelids-for achieving eye closure. Correcting upper eyelid function involves facilitating the component of eye closure that is in the same direction as gravity and is, therefore, less complicated and favorable outcomes than correction of lower lid. Aesthetic aspects should be considered to correct the asymmetry caused by facial palsy. Lower eyelid function involves a force that opposes gravity for eye closure, which makes correction of lower eyelid ectropion more challenging than surgery for the upper eyelid, particularly in terms of effecting a sustained correction. Initially, proper ophthalmic evaluation is required, including identifying the chronicity and severity of ectropion. Also, it is important to determine whether or not lateral canthoplasty is necessary. The lateral tarsal strip procedure is commonly used for lower lid correction. However, effective lower lid correction can be achieved with better cosmesis when extensive supporting techniques are applied, including those involving cheek tissue.

[Staged complex treatment of paralytic lagophthalmos (case report)]

Paralytic lagophthalmos, resulting from facial nerve palsy, is a difficult medical and social issue that requires cooperation of different specialists. Complications that arise in paralytic lagophthalmos may cause significant vision loss and even eye loss. Various techniques of paralytic lagophthalmos correction are used to protect the cornea and restore eyelid anatomy and functions. These comprise palliative (conservative), surgical, and alternative treatments (such as botulinum toxin type A therapy). Surgical treatment of paralytic lagophthalmos patients often has to be staged and complex. This article presents a clinical case of a female patient with paralytic lagophthalmos complicated by corneal perforation. Her staged complex treatment included lower eyelid surgery, chemodenervation of the upper eyelid levator and optical reconstructive surgery. The following positive results were achieved: the protective function of the eyelids was restored, residual visual functions - preserved, the risk of eye loss - eliminated, and the asymmetry between the two halves of the face - corrected.

Microbial synthesis of gold nanoparticles: current status and future prospects

Gold nanoparticles have been employed in biomedicine since the last decade because of their unique optical, electrical and photothermal properties. Present review discusses the microbial synthesis, properties and biomedical applications of gold nanoparticles. Different microbial synthesis strategies used so far for obtaining better yield and stability have been described. It also includes different methods used for the characterization and analysis of gold nanoparticles, viz. UV-visible spectroscopy, Fourier transform infrared spectroscopy, X ray diffraction spectroscopy, scanning electron microscopy, ransmission electron microscopy, atomic force microscopy, electron dispersive X ray, X ray photoelectron spectroscopy and cyclic voltametry. The different mechanisms involved in microbial synthesis of gold nanoparticles have been discussed. The information related to applications of microbially synthesized gold nanoparticles and patents on microbial synthesis of gold nanoparticles has been summarized.

Gold weight implantation and lateral tarsorrhaphy for upper eyelid paralysis

BACKGROUND

Upper eyelid paralysis leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness.

METHODS

Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy were identified from our prospective database and reviewed.

RESULTS

Sixty-three patients were identified, 36 of whom underwent immediate reanimation procedure either during cancer excision (n = 35) or repair of facial laceration (n = 1). Twenty-seven patients had a delayed procedure either following tumour excision (n = 21) or unresolved Bell's palsy (n = 3), or facial palsy due to complex craniofacial fracture (n = 3). Nine patients required revision to achieve optimal weight. Fifty-two patients had full eye closure. The remaining 11 patients had almost complete eye closure.

CONCLUSIONS

Facial paralysis is devastating for the patient and immediate facial reanimation should be performed. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective in achieving eye closure.

Facial nerve damage following surgery for cerebellopontine angle tumours. Prevention and comprehensive treatment

Facial nerve (CN VII) palsy or even its transient paresis causes physical disability but is also a psychosocial problem. Immediately after vestibular schwannoma removal, different degrees of CN VII paresis occur in 20-70% of patients. Facial nerve paresis is observed in 10-40% after surgery of cerebellopontine angle meningiomas. Postoperative facial nerve weakness significantly reduces or completely withdraws with time in the majority of cases. However, even if prognosis for CN VII regeneration is good, proper management is needed because of the potential for serious ophthalmic complications. In this paper, the authors raise the issue of perioperative prophylaxis and comprehensive treatment of postoperative paresis of CN VII. Prophylaxis and treatment of ophthalmic complications are discussed. Current trends in the treatment of intraoperative loss of facial nerve continuity, management of facial paresis with good prognosis and dealing with facial palsy with no spontaneous recovery are also described in the paper.

Immediate Eye Rehabilitation at the Time of Facial Nerve Sacrifice

Objective. In the setting of known facial nerve sacrifice or injury, patients require precautions to prevent exposure keratitis and the morbidity that follows. One recommended treatment is surgical placement of a gold weight with or without lateral tarsal strip. In patients in whom the facial nerve has been sacrificed, it is unknown whether rehabilitation should be simultaneous or in the perioperative period.

Study Design and Setting. Case series with chart review of patients who underwent immediate rehabilitation of the eye (gold weight and lateral tarsal strip) following facial nerve resection.

Subjects and Methods. From 1998 to 2009, 52 patients were studied. Postoperative ophthalmologic complications and the need for revision surgeries were measured.

Results. A gold weight was placed in all patients, and 48 of 52 (92%) simultaneous lateral tarsal strips were performed. The facial nerve was sacrificed in 51 of 52 (88%) patients, and the remaining patient had a known preoperative facial nerve paralysis. Thirty-six of 52 (69%) required free tissue transfer for reconstruction, underscoring the extensive resections performed. A 1.2-g gold weight was placed in 50 of 52 (96%) patients. Three (6%) patients required gold weight revision with a larger weight and 3 (6%) for extrusion. Eight (16.7%) patients underwent revision of the lateral tarsal strip for ectropion.

Conclusions. No patients developed ophthalmologic complications. Patients undergoing radical surgical resections with known or suspected injury of the facial nerve should be considered for simultaneous rehabilitation of the upper and lower eye.

Facial nerve palsy: providing eye comfort and cosmesis

Development of facial nerve palsy (FNP) may lead to dramatic change in the patient's facial function, expression, and emotions. The ophthalmologist may play an important role in the initial evaluation, and the long-term management of patients with new-onset of FNP. In patients with expected temporary facial weakness, no efforts should be wasted to ensure proper corneal protection. Patients with permanent functional deficit may require combination of surgical procedures tailored to the patient's clinical findings that may require good eye comfort and cosmesis.

Facial nerve palsy: anatomy, etiology, evaluation, and management

The ophthalmologist may be the first clinician to see a patient who presents with acute facial nerve palsy. Under such circumstances the ophthalmologist should make every effort to establish the underlying cause of the facial palsy and ensure that the patient's cornea is adequately protected. This article reviews the anatomy of the facial nerve, the varied disorders that may cause a facial palsy, a detailed evaluation of such a patient, and the various medical and surgical treatments available.

Ocular outcomes after gold weight placement and facial nerve resection

OBJECTIVE: To assess the effectiveness of acute gold weight placement after facial nerve resection and to determine the role of concomitant lower eyelid procedures.

STUDY DESIGN: Retrospective review.

SUBJECTS AND METHODS: Twenty-two patients who received an upper eyelid gold weight at the time of parotidectomy and facial nerve resection were reviewed to assess ocular outcomes.

RESULTS: After gold weight placement, twelve patients (12 of 22, 54.5%) subsequently presented with symptomatic ectropion (n = 9) and/or lagophthalmos (n = 5). Nine patients received a lower eyelid procedure (7 tarsal strips only, 1 tarsal strip combined with a lateral tarsorrhaphy, and 1 lateral tarsorrhaphy only). Six patients, in addition to a gold weight, also underwent a static sling to the midface at the time of facial nerve resection. None of these 6 received a subsequent lower eyelid procedure. Two patients required gold weight upsizing. Two patients required weight removal.

CONCLUSIONS: Insertion of 1.2 gm upper eyelid weight with placement of midface sling is recommended at the time of facial nerve resection. Due to the need to tighten the lower eyelid in many of these patients, we now also consider performing a tarsal strip procedure at the time of facial nerve resection in any patient with pre-existing lower lid laxity.

Restoration of eyelid closure in facial paralysis using artificial muscle: preliminary cadaveric analysis

OBJECTIVES

Electroactive polymer artificial muscle is an emerging technology that has the potential to be used in rehabilitating facial movement in patients with paralysis. These electroactive polymers act like human muscles by expanding and contracting based on variable voltage input levels. The authors seek to establish a reproducible eyelid blink with artificial muscle. The aim of this proof of concept study is to determine whether eyelid closure can be created with a novel eyelid sling model.

STUDY DESIGN

A human cadaver study was performed.

METHODS

With use of four cadaver heads, an extended upper and lower blepharoplasty incision was used to secure an upper and lower expanded polytetrafluoroethylene implant in the medial orbital wall and tarsal plates. The slings were passed through a hole drilled in the lateral orbital wall or around a titanium screw. Lateral pull on the sling created eyelid closure, and the necessary distance of pull was measured.

RESULTS

The eyelid sling mechanism functioned to achieve complete eyelid closure. Less tension was required for eyelid closure when the sling was placed in both eyelids (3 mm of pull instead of 6 mm).

CONCLUSIONS

The application of artificial muscle to a range of problems that affect both patient morbidity and quality of life is promising. Eyelid closure was created in a cadaver model using a novel sling, but future studies will need to address the feasibility of a prototype artificial muscle eyelid device in humans.

Outcomes of periocular reconstruction for facial nerve paralysis in cancer patients

BACKGROUND

Facial nerve paralysis is a common event in patients with head and neck cancer or metastasis of cancer to the parotid region. The aim of this study was to evaluate the outcomes of periocular reconstruction for facial nerve paralysis in cancer patients.

METHODS

The medical records of all patients who had undergone periocular surgery for facial nerve paralysis between January of 1999 and December of 2003 were retrospectively reviewed. The outcome measures included the ocular symptoms and signs, improvement in symptoms of exposure keratopathy postoperatively, timing of periocular surgery in relation to radiotherapy, and surgical complications.

RESULTS

Preoperative symptoms included burning sensation (25 of 78 patients), difficulty with vision (30 of 78), frequent use of lubricating drops and ointments (52 of 78), and excessive tearing (37 of 78). The degree of lagophthalmos ranged from 1.5 to 12 mm (mean, 6.5 mm) preoperatively and from 0 to 4.5 mm (mean, 1.5 mm) postoperatively. Seventy-eight patients had gold weight placement; 72 of them also had lateral tarsorrhaphy, 56 had lower eyelid tightening via a lateral tarsal strip procedure in addition to the gold weight and lateral tarsorrhaphy, and 22 had brow elevation in addition to all the above-mentioned procedures. Four also required a medial tarsorrhaphy. All patients reported less dependence on lubricating drops and ointments after periocular surgery. Eighteen of 25 patients who had foreign body sensation as their main preoperative symptom experienced improvement after surgery. Forty-four patients had radiotherapy to the head and neck region. Twenty-seven patients completed radiotherapy before and 17 after periocular reconstruction. Complication rates were low and comparable in both preoperative and postoperative radiation groups.

CONCLUSIONS

Periocular reconstruction for facial paralysis results in improvement of exposure keratopathy and less dependence on lubricating drops and ointments. Complications are minimal and infrequent. The timing of external beam radiotherapy does not affect the outcomes of periocular surgery.

Gold weight implantation for rehabilitation of the paralysed eyelid

Patients with complete facial nerve palsy are at risk of severe eye complications due to corneal exposure. Gold weight implantation improves function, cosmetic appearance and morbidity. Three patients with nerve palsy underwent insertion of precisely prepared gold weights between May 2000 and December 2001. Individual gold weights were implanted into a small pocket between the orbicularis oculi and the tarsal plate of the upper eyelid, fitting the curvature of the eye. According to follow-up examinations (after at least 5 years), none of the gold weights had extruded; all patients experienced marked improvement of their dry-eye symptoms and expressed a high degree of satisfaction. Implantation of gold weights is effective and should be considered in all patients for the management of paralytic lagophthalmos.

Ophthalmic Management of Facial Nerve Palsy: A Review

Facial nerve palsy affects individuals of all ages, races, and sexes. Psychological and functional implications of the paralysis present a devastating management problem to those afflicted, as well as the carriers. Since Sir Charles Bell's original description of facial palsy in 1821, our understanding and treatment options have expanded. It is essential that a multidisciplinary approach, encompassing ophthalmologists; Ear, Nose, and Throat surgeons; plastic surgeons; and psychologists work closely to optimize patient management in a staged approach. Although the etiology remains unknown, strong histological, cerebral spinal fluid, and radiological evidence suggests a possible association with herpes simplex virus in idiopathic facial nerve palsy (Bell's palsy). The use of steroids has been suggested as a means of limiting facial nerve damage in the acute phase. Unfortunately, no single randomized control trial has achieved an unquestionable benefit with the use of oral steroid therapy and thus remains controversial. In the acute phase, ophthalmologists play a pivotal role in preventing irreversible blindness from corneal exposure. This may be successfully achieved by using intensive lubrication, medical therapy (botulinum toxin), or surgery (upper lid weighting or tarsorraphy). Once the cornea is adequately protected and recovery deemed unlikely, longer term planning for eyelid and facial reanimation may take place in an individualized manner. Onset is sudden and management potentially lengthy. Physician empathy, knowledge, and experience are essential in averting long-term lifestyle and psychological discomfort for patients.

Modified Procedure for Secondary Facial Rehabilitation Following Total Bilateral Irreversible Peripheral Facial Palsy

We present the case of a middle-aged gentleman who developed total bilateral irreversible peripheral facial palsy over a period of 10 years, starting with palsy of the marginal mandibular and buccal branches of the facial nerve and progressing to the zygomatic and temporal branches. The patient did not develop any other neurological symptoms, and all neurological and other tests have remained negative over the last 10 years. Dripping of saliva and inability to close the mouth necessitated reanimation of the perioral region with the help of a fascia lata graft fixed to the fascia of the masseter muscles. The increasing lagophthalmos and associated eye problems were alleviated with a temporal muscle transposition combined with a lengthening procedure using the temporal fascia, passed through the upper and lower eyelids and hooked around the medial canthal ligament. The fascia strips were sutured not to the canthal ligament itself, but to each other, thereby placing equal self-adjusted tension on the upper and lower eyelids. Both operations were successful and improved eating and eye closure functions, allowing resolution of the eye symptoms.

Facial Paralysis and Surgical Rehabilitation: A Quality Of Life Analysis in a Cohort of 1,595 Patients after Acoustic Neuroma Surgery

OBJECTIVES

On the basis of survey results of the Acoustic Neuroma Association, we report patient ratings of facial dysfunction and outcomes for various facial rehabilitative therapies after surgical treatment of acoustic neuroma (AN). We assessed patients' perceived quality of life (QOL) and reviewed the literature regarding facial dysfunction and its management associated with AN.

STUDY DESIGN

The Acoustic Neuroma Association mailed a detailed questionnaire to 2,372 members to identify preoperative and postoperative symptoms, complications, and long-term effects on physical and psychosocial function. A cohort of 1,595 (82.2%) respondents who underwent surgical treatment of ANs reported their experiences with facial dysfunction.

PATIENTS

Of all 1,940 survey respondents, 1,682 of 1,875 that had ANs underwent surgical treatment. The study included 1,595 patients with ANs (82.2% of all respondents) who underwent surgical treatment by way of the translabyrinthine, suboccipital, or middle fossa approaches and excluded 87 respondents who did not report the type of surgical approach.

METHODS

Respondents answered questions intended to qualify and quantify the degree that facial dysfunction impacted QOL parameters. Responses were analyzed for tumor size, surgical approach, patient age, and sex. Statistical analysis was performed using SPSS software.

RESULTS

In our analysis, 11% of all respondents experienced some degree of preoperative facial weakness or eye problems. Of all respondents, 45.5% (725 patients) experienced worsened facial weakness caused by surgery, and of these, 72% reported that it was permanent. The most commonly used successful therapy for facial reanimation for 271 (19.6%) patients was placement of a gold weight. The factor most often associated with poor outcome was a large tumor. Of all respondents, 28% felt significantly affected by facial weakness, 63% felt their smile was symmetric, and 70% were content "quite a bit" or "very much" with their QOL.

CONCLUSIONS

In this large cohort study of AN patients, facial dysfunction was a significant morbidity. Physicians should be aware of the risk factors identified, specifically large tumor size and the impact facial dysfunction has on QOL, when counseling patients regarding optimal management of AN.

Ophthalmic management of facial nerve palsy

The ophthalmologist plays a pivotal role in the evaluation and rehabilitation of patients with facial nerve palsy. It is crucial to recognize and treat the potentially life-threatening underlying causes. The immediate ophthalmic priority is to ensure adequate corneal protection. The medium to long-term management consists of treatment of epiphora, hyperkinetic disorders secondary to aberrant regeneration and poor cosmesis. Patients should be appropriately referred for general facial re-animation. This review aims to provide a guide to the management of this complex condition.

Retrograde weight implantation for correction of lagophthalmos

OBJECTIVES

Gold weight implantation is the most commonly used method for surgical correction of paralytic lagophthalmos. Numerous techniques for placement of the weight have been described, yet complications with these methods continue to occur (implant migration or extrusion, wound infection, failure to correct the lagophthalmos, and excessive postoperative ptosis). We developed a retrograde, postlevator aponeurosis method for implantation to improve the placement and fixation of the weight. This study describes the rationale, technique, and surgical outcome of the retrograde approach.

STUDY DESIGN

Retrospective analysis.

METHODS

Data maintained and collected on 25 consecutive cases of retrograde upper lid weight implantation for paralytic lagophthalmos. Pre- and postoperative photographs were obtained, and patients were followed for at least 6 months. All procedures were performed by or under the direction of a single surgeon at tertiary academic medical centers (University of California, San Diego and University of Zurich, Switzerland).

RESULTS

Twenty-five consecutive patients were evaluated, 16 male and 9 female, ranging in age from 27 to 86 years. There were no surgical failures or perioperative complications and no instances of implant migration or extrusion. One patient developed a delayed infection requiring removal of the implant, and one patient required replacement of the gold weight with a platinum chain implant to better fit the contour of her eyelid.

CONCLUSIONS

Retrograde implantation allows more accurate placement of the weight while creating a permanent circumferential seal for fixation. The procedure is minimally invasive, less traumatic than previous methods, and produces an excellent cosmetic result. The efficacy has been demonstrated in the outcome of the 25 cases described in this study.