Periorbital Autologous Fat Grafting in Facial Nerve Palsy

Eyelid Skin Grafting in Young Patients with Facial Nerve Palsy

Background: The aim of this study is to report outcomes of eyelid full-thickness skin grafting augmentation in facial nerve palsy (FNP) patients younger than 50 years of age. Methods: In a retrospective, consecutive case series, nine eyelid skin grafts performed on eight FNP patients with skin contraction (five females; median age 42 years [range, 17-47]) are presented. In most cases, upper eyelid skin grafting was combined with levator recession and anterior lamellar repositioning. Lower eyelid skin grafting was combined with lower retractors recession in all cases. Functional and cosmetic outcomes were measured preoperatively and at early (1-3 months), intermediate (3-6 months), and late (≥12 months) follow-up. Results: The corneal score improved at early follow-up (p = 0.03) and remained improved at late follow-up (p = 0.042). The gentle closure lagophthalmos was improved at late follow-up (p = 0.042). (p = 0.048). The grades of graft color, edge/skin interface, and size improved at 3-6 months post-grafting and remained improved at late follow-up (p < 0.05). Over the follow-up, four patients (50%) were recommended to have further surgical procedures. Conclusions: The preliminary results from this small cohort suggest that eyelid skin grafting is a viable option for young patients prioritizing cosmesis. This technique warrants consideration for its functional benefits.

Lower eyelid lengthening in facial nerve palsy: when is a periosteal flap required?

BACKGROUND/AIMS

To present a case series of patients with facial nerve palsy (FNP) undergoing lower eyelid surgery where inadequate horizontal tarsal length was encountered and managed with a periosteal flap.

METHODS

A two-centre retrospective, non-comparative case series of all patients with FNP who underwent lower eyelid periosteal flap procedures. Theatre records identified all such procedures performed by, or under the supervision of, one of two surgeons (RM, BCP) between November 2018 and November 2020. Outcome measures, including the Cornea, static Asymmetry, Dynamic function, Synkinesis grading score, were measured preoperatively and postoperatively.

RESULTS

All 17 patients had undergone medial canthal tendon (MCT) plication. Six had previously undergone MCT plication then were listed for further lower eyelid surgery. In 11 cases, horizontal deficiency was encountered intraoperatively, immediately following MCT plication. Four patients were surgery-naïve. 94% were within the 'contraction phase' of FNP (ie, greater than 1-year duration); eight (45%) had previously undergone lower eyelid shortening procedures (such as lateral tarsal strip procedure, LTS). All patients had improved lower eyelid position postoperatively, although at 1-year postoperation, four patients require redo lower eyelid surgery.

CONCLUSIONS

MCT plication and stabilisation appear to be closely linked to the need for lower eyelid lengthening procedures, particularly in patients who have also undergone LTS and/or those within the 'contraction phase' of FNP. Unnecessary loss of horizontal tarsal length (particularly during LTS procedures) must be avoided in patients with FNP. Surgeons managing such patients should take care to identify inadvertent eyelid shortening early and be prepared to perform a lateral periosteal flap when required.

Horizontal shortening of the lower eyelid margin in facial nerve palsy

BACKGROUND/OBJECTIVES

To determine whether horizontal lower eyelid margin length shortens following facial nerve palsy (FNP).

SUBJECTS/METHODS

A single-centre retrospective audit of lower eyelid margin horizontal length, measuring from the lower lacrimal punctum to lateral canthal angle with a straight plastic ruler, with the eyelid on gentle stretch ('punctum-to-canthus (PC) distance'), recorded in all FNP patients reviewed in July-September 2021. Affected and fellow eyes were compared using parametric testing.

RESULTS

Forty-one patients were reviewed. Seventeen were excluded due to previous surgery that would lengthen (e.g., periosteal flap) or shorten (e.g., lateral tarsal strip) the lower eyelid margin. Of the remaining 24, mean age was 52.5 years (range, 27-79) and 54% were female. Mean PC distance was significantly shorter in affected eyes (26.0 mm, range: 22-34 mm) compared to fellow eyes (27.5 mm, 24-35 mm) (paired t-test, T(23) = 6.06, p < 0.00001). Mean difference between both eyes' PC distance was 1.5 mm (0-4 mm). Only three patients were still in the 'paralytic phase' (i.e., <1 year since FNP onset), and difference in PC distance was 0 mm in all three. A reduction in lower eyelid PC distance was weakly associated with a reduction in upper eyelid lid-margin-to-brow distance (R = 0.4775, p = 0.0286).

CONCLUSIONS

The lower eyelid margin appears to shorten horizontally following FNP. This study provides proof-of-concept for the use of measuring PC distance in patients with FNP as an additional tool for the overall assessment of soft tissue contraction following FNP. It may help identify patients in whom further lower eyelid margin shortening should be avoided and in whom eyelid lengthening may be required.

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.

Advances in facial nerve management in the head and neck cancer patient

PURPOSE OF REVIEW

The purpose of this review is to summarize best practices in facial nerve management for patients with head and neck cancer. In addition, we provide a review of recent literature on novel innovations and techniques in facial reanimation surgery.

RECENT FINDINGS

Although recommended when tumor ablation surgery requires facial nerve sacrifice, facial reanimation procedures are not always performed. Concurrent dynamic facial reanimation with masseteric nerve transfers and cable graft repair can preserve native facial muscle function. Static suspension can provide facial support and immediate resting symmetry for patients. Eyelid weight and eye care should not be delayed, particularly in patients with trigeminal sensory deficits. Choice of neural source to innervate a gracilis-free muscle transfer for smile reanimation remains controversial; however, new techniques, such as dual innervation and multivector muscle transfer, may improve aesthetic and functional outcomes.

SUMMARY

Management of the facial nerve in the setting of head and neck cancer presents unique challenges. When possible, simultaneous oncologic resection and facial reanimation is ideal given the open surgical field, newly dissected and electrically stimulatable facial nerve branches, as well as minimizing postoperative healing time to prevent postsurgical treatment delays. A coordinated approach to facial nerve management with a multidisciplinary surgical team may help provide optimal, comprehensive care.

Functional and aesthetic outcomes of eyelid skin grafting in facial nerve palsy

AIM

To report the functional and aesthetic outcomes of eyelid full-thickness skin grafting (FTSG) in patients with facial nerve palsy (FNP).

METHODS

This is a retrospective, non-comparative, single-centre review of all patients with FNP who underwent FTSG over an 8-year period. Functional outcomes were collected through case notes review: CADS (cornea, static asymmetry and dynamic and synkinesis) score facial nerve grading and lagophthalmos on blink, gentle and forced closure. Marginal reflex distance (MRD1 and MRD2) was calculated on standardised photographs. The aesthetic outcomes were assessed objectively by two blinded independent assessors who assessed standardised photographs based on a mutually agreed grading scale. Both functional and aesthetic outcomes were measured preoperatively, and at early (1-3 months), intermediate (3-6 months) and late (>9 months) postoperative periods.

RESULTS

A total of 28 eyelid FTSGs were performed on 21 patients (11 female, 10 male) between 2008 and 2016. The mean age was 68 (range, 16-89) years and the mean follow-up was 20.8 (range, 12-30) months. The CADS score (cornea (p<0.001), static asymmetry (p<0.001), dynamic function (p<0.001)), MRD2 (p=0.002) and lagophthalmos (blink (p=0.003), gentle (p<0.001), forced (p=0.003)) improved through early and late postoperative periods. Aesthetically, the grafts appeared to look natural in terms of colour, surface contour and graft edge from the intermediate postoperative period and continued to improve significantly by the late postoperative period.

CONCLUSION

The use of periocular FTSG is effective in improving lagophthalmos and periorbital symmetry in patients with FNP where skin contraction exists. They should be considered as an adjunct to other oculoplastic procedures for both functional and aesthetic rehabilitation.