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Knoedler S, Knoedler L, Hoch CC, Kauke-Navarro M, Kehrer A, Friedman L, Prantl L, Machens HG, Orgill DP, Panayi AC. An ACS-NSQIP Data Analysis of 30-Day Outcomes Following Surgery for Bell's Palsy. J Craniofac Surg 2024; 35:23-28. [PMID: 37695075 PMCID: PMC10841222 DOI: 10.1097/scs.0000000000009739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND There exists a paucity of large-scale, multi-institutional studies that investigate the outcomes of surgery for Bell's palsy (BP). Here, we utilize a large, multi-institutional database to study the risk factors and early-stage outcomes following surgical procedures in BP. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2019) to identify patients who underwent surgery for the diagnosis of BP. We extracted data on comorbidities and preoperative blood values, and 30-day postoperative outcomes. RESULTS Two hundred fifty-seven patients who underwent surgery for BP symptoms over the 12-year review period were identified. Muscle grafts (n=50; 19%) and fascial grafts (n=48; 19%) accounted for the majority of procedures. The most common comorbidities were hypertension (n=89; 35%) and obesity (n=79; 31%). Complications occurred in 26 (10.1%) cases. Additionally, length of hospital stay was significantly associated with both surgical and medical complications (3.9±4.7 versus 1.5±2.0; P <0.01) and (3.2±3.8 versus 1.4±2.0; P <0.01), respectively. Preoperative creatinine, blood urea nitrogen, and alkaline phosphatase were identified as potential predictors of poor postoperative outcomes. CONCLUSION Based on multi-institutional analysis, complication rates following surgery for BP were found to be overall low and seen to correlate with length of hospital stay. Reoperations and readmissions were the most frequent complications after surgery for BP. The preoperative evaluation of routine laboratory values may help refine patient eligibility and risk stratification. In addition, our findings call for future large-scale prospective studies in the field of facial palsy surgery to further improve the quality of care and optimize perioperative protocols.
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Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Plastic and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Cosima C. Hoch
- Department of Otolaryngology, Head and Neck Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Leigh Friedman
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Hans-Guenther Machens
- Department of Plastic and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dennis P. Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Adriana C. Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Hussain A. Dynamic eyelid reconstruction in facial nerve palsy. Surv Ophthalmol 2023; 68:985-1001. [PMID: 37201598 DOI: 10.1016/j.survophthal.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
The consequences of facial nerve palsy and the secondary inability of eyelid closure and blink may lead to devastating complications for the patient, including blindness. Reconstruction techniques to improve eyelid position and function can be broadly classified into 'static' and 'dynamic' techniques. Generally, ophthalmologists have been familiar with static procedures such as upper eyelid loading, tarsorrhaphy, canthoplasty, and lower eyelid suspension. Recently, dynamic techniques are being increasingly described for patients who require definitive strategies to improve eyelid function, once the initial critical goals of corneal protection and vision preservation have been achieved. The choice of technique(s) is dependent upon the status of the main protractor of the eyelid region, as well as the age of the patient, the patient's morbidities and expectations, and surgeon preference. This review shall first describe the clinical and surgical anatomy relevant to the ophthalmic consequences of facial paralysis and discuss methods of defining function and outcomes. A comprehensive review of dynamic eyelid reconstruction is then presented with a discussion of the literature. These various techniques may not be familiar to all clinicians. It is important that ophthalmic surgeons are aware of all options available for their patients. Furthermore, eye care providers must have an understanding of when referral may be appropriate to provide timely intervention and optimal chances of recovery.
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Affiliation(s)
- Ahsen Hussain
- Department of Ophthalmology and Visual Sciences, Dalhousie University, Halifax, NS, Canada.
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3
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Lu GN, Flynn J. Facial Nerve Reconstruction. Otolaryngol Clin North Am 2023:S0030-6665(23)00050-6. [PMID: 37217366 DOI: 10.1016/j.otc.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Facial palsy causes profound facial disfigurement in addition to compromise of eye closure, speech articulation, oral competence, and emotive expression. Facial reanimation is paramount to reduce functional sequelae and improve patient quality of life. This article discusses facial nerve reconstruction focusing on the setting of head and neck reconstruction.
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Affiliation(s)
- Guanning Nina Lu
- University of Washington, 325 9th Avenue 4 West, Seattle, WA 98104, USA.
| | - John Flynn
- University of Kansas Medical Center, 4000 Cambridge Street, Kansas City, KS 66103, USA
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Akella SS, MacIntosh PW, Setabutr P. Kinking of palpebral spring mimicking extrusion. Orbit 2023; 42:224-225. [PMID: 33641592 DOI: 10.1080/01676830.2021.1890136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Sruti S Akella
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Peter W MacIntosh
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Pete Setabutr
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
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5
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Lowndes Correa Francalacci R, Lessa S, da Costa Aboudib JH. Auricular Cartilage Graft for Lengthening Levator Muscle Aponeurosis With Ectropion Correction for Paralytic Lagophthalmos. Aesthet Surg J 2023; 43:13-23. [PMID: 35788264 DOI: 10.1093/asj/sjac181] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Indexed: 01/18/2023] Open
Abstract
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
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Affiliation(s)
| | - Sérgio Lessa
- Postgraduate Program in Oculoplastic Surgery, State University of Rio de Janeiro, State University of Rio de Janeiro (UERJ), Rio de Janeiro-RJ, Brazil
| | - José Horácio da Costa Aboudib
- Postgraduate Program in Physiopathology and Surgical Sciences, State University of Rio de Janeiro (UERJ), Rio de Janeiro-RJ, Brazil
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Roth S, Moss HE, Vajaranant TS, Sweitzer B. Perioperative Care of the Patient with Eye Pathologies Undergoing Nonocular Surgery. Anesthesiology 2022; 137:620-643. [PMID: 36179149 PMCID: PMC9588701 DOI: 10.1097/aln.0000000000004338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The authors reviewed perioperative ocular complications and implications of ocular diseases during nonocular surgeries. Exposure keratopathy, the most common perioperative eye injury, is preventable. Ischemic optic neuropathy, the leading cause of perioperative blindness, has well-defined risk factors. The incidence of ischemic optic neuropathy after spine fusion, but not cardiac surgery, has been decreasing. Central retinal artery occlusion during spine fusion surgery can be prevented by protecting eyes from compression. Perioperative acute angle closure glaucoma is a vision-threatening emergency that can be successfully treated by rapid reduction of elevated intraocular pressure. Differential diagnoses of visual dysfunction in the perioperative period and treatments are detailed. Although glaucoma is increasingly prevalent and often questions arise concerning perioperative anesthetic management, evidence-based recommendations to guide safe anesthesia care in patients with glaucoma are currently lacking. Patients with low vision present challenges to the anesthesia provider that are becoming more common as the population ages.
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Affiliation(s)
- Steven Roth
- Department of Anesthesiology, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - Heather E Moss
- Departments of Ophthalmology and Neurology & Neurologic Sciences, Stanford University, Palo Alto, California
| | - Thasarat Sutabutr Vajaranant
- Department of Ophthalmology and Visual Science, University of Illinois at Chicago, College of Medicine, Chicago, Illinois
| | - BobbieJean Sweitzer
- University of Virginia, Charlottesville, Virginia; Perioperative Medicine, Inova Health System, Falls Church, Virginia
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Facial nerve paralysis: A review on the evolution of implantable prosthesis in restoring dynamic eye closure. J Plast Reconstr Aesthet Surg 2021; 75:248-257. [PMID: 34635457 DOI: 10.1016/j.bjps.2021.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 07/10/2021] [Accepted: 08/26/2021] [Indexed: 11/22/2022]
Abstract
Facial nerve paralysis (FNP) is a debilitating condition that leaves those affected with disfigurement and loss of function. The most important function of the facial nerve is protecting the eye through eye closure and blinking. A series of reanimation techniques have been reported to restore dynamic function in FNP, but the lack of a universally accepted method that is reliable and reproducible with immediate effect has led to the introduction of several implantable devices. Most of these devices have been applied to assist blinking; however, the delicate anatomy and unique mechanics of eye closure are difficult to replicate. Lid loading is the most frequently used implant today, which is a passive device that can aid in volitional eye closure but has a limited effect on blinking. Dynamic action can be achieved with active prostheses but achieving successful long-term function remains elusive. Device action must also be coupled with a real-time feedback mechanism in order to capture the natural variation in facial muscle movements. This review discusses all prostheses used for restoring eye closure and blinking to date and explores their relative merits.
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8
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Abstract
Posterior fossa meningiomas that impinge on structures of the temporal bone or clivus may be difficult to access for optimal resection that maximizes tumor control and minimizes short- and long-term morbidities. To address this challenge, the contemporary neurosurgery-neurotology team works collaboratively by managing patients jointly at every stage of care: preoperative evaluation, intraoperative intervention, and postoperative treatment. The neurotologist is important at all stages of posterior fossa meningioma surgery. First, detailed preoperative evaluation of auditory, facial, vestibular, and lower cranial nerve integrity enables assessment of new neurologic deficit risk, prognosis of functional recovery, and pros and cons of candidate surgical approaches. Second, intraoperative partitioning of surgical steps by provider and adopting an overlapping tumor resection philosophy creates an efficient and confident surgical team built on trust. Third, postoperative closure of cerebrospinal fluid leak and treatment of facial weakness, audiovestibular dysfunction, and voicing and swallowing impairments organized by the neurotologist reduces the impact of negative outcomes. The role of the neurotologist in posterior fossa meningioma surgery is to deliver nuanced evaluative metrics, facilitate shared decision making, perform precise bone and soft tissue microsurgery, and mitigate perioperative morbidities.
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9
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Abstract
The field of facial paralysis requires the reconstructive surgeon to apply a wide spectrum of reconstructive and aesthetic principles, using a comprehensive array of surgical tools, including microsurgery, peripheral nerve surgery, and aesthetic facial surgery on the road to optimize patient outcomes. The distinct deficits created by different anatomical levels of facial nerve injury require a fundamental understanding of facial nerve anatomy. Palsy duration, followed by location and mechanism, will determine mimetic muscle salvageability, by means of either direct repair, grafting, or nerve transfers, whereas longer palsy durations will necessitate introducing a new neuromuscular unit, whether by muscle transfer or free functional muscle transplant. A thorough history, physical examination, and basic understanding of ancillary studies, emphasizing palsy duration, location, and mechanism of injury, are critical in evaluation, prognostication, and treatment strategies in traumatic facial palsy patients. The importance of ancillary and aesthetic procedures cannot be overstated. Although these do not provide motion, they constitute essential tools in the treatment of facial paralysis, providing both protective and improved aesthetic outcomes, yielding the highest impact in final surgeon and patient satisfaction, bringing our patients to smile not only on the outside, but also on the inside.
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10
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Salloum G, Carruth BP, Hill RH, Czyz CN, Bersani TA. Transitioning from a gold weight to an "enhanced" palpebral spring in the management of paralytic lagophthalmos secondary to facial nerve palsy. Orbit 2019; 38:119-123. [PMID: 30047813 DOI: 10.1080/01676830.2018.1497067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 07/02/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To analyze the outcomes of patients who transitioned from a weight to a spring. METHODS Case series original investigation. Five consecutive patients undergoing "enhanced" palpebral spring insertion status post gold weight insertion were identified. Outcome measures included visual acuity, lagophthalmos, margin reflex distance 1, and corneal epithelial defects. Subjective outcomes included need for eye lubrication, closure and rapid blink, and symptoms of discomfort and dryness. This study was reviewed by an accredited Institutional Review Board (IRB) and granted exempt status according to federal regulations. RESULTS Mean visual acuity post weight versus spring was 20/200 (logMAR 1.0, Std Dev. -0.6) and 20/25 (logMAR 0.1, Std Dev. -0.1), respectively (p = 0.0214, CI 0.231 to 1.670). Mean lagophthalmos post weight (3.5 mm, Std Dev. -2.8) versus post spring (0.2 mm, Std Dev. -0.5). Margin reflex distance 1 improved by a mean of 1.4 mm (gold wt -0.6, Std Dev. -0.5/spring -2.0, Std Dev. -0.4) (p = 0.0016, CI -1.773 to -0.977). Superficial punctate keratopathy was present in all patients with weights and present in no patients post transition (p = 0.0079). Post transition, three of five patients rarely required lubrication and experienced a more satisfactory blink rate. CONCLUSION Patients with lagophthalmos due to cranial nerve seven palsy who have undergone gold weight placement but continue to exhibit objective and subjective corneal symptoms may have symptomatic improvement with the transition to a palpebral spring.
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Affiliation(s)
- George Salloum
- a Department of Ophthalmology , State University of New York Upstate Medical Center , Syracuse , New York , USA
| | - Bryant P Carruth
- a Department of Ophthalmology , State University of New York Upstate Medical Center , Syracuse , New York , USA
| | - Robert H Hill
- a Department of Ophthalmology , State University of New York Upstate Medical Center , Syracuse , New York , USA
| | - Craig N Czyz
- b Section of Oculofacial Plastic and Reconstructive Surgery, Division of Ophthalmology , Ohio University/Doctors Hospital , Columbus , Ohio , USA
- c Department of Ophthalmology , Oral and Maxillofacial Surgery, Grant Medical Center , Columbus , Ohio , USA
| | - Thomas A Bersani
- a Department of Ophthalmology , State University of New York Upstate Medical Center , Syracuse , New York , USA
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11
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Grusha YO, Sheptulin VA, Prause JU, Danilov SS. [Hyaluronic acid gel implants for correction of pathological conditions of the orbit and eyelids]. Vestn Oftalmol 2018; 134:61-71. [PMID: 30499541 DOI: 10.17116/oftalma201813405161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the effectiveness of injectable implants made of hyaluronic acid gel (HAG) in ophthalmoplastics. MATERIAL AND METHODS The study included 57 patients (37 patients with lagophthalmos related to acute or chronic facial nerve palsy, endocrine ophthalmopathy; 20 patients with enophthalmos, anophthalmic syndrome). Depending on filler particle size, the patients received either intrapalpebral or intraorbital HAG injection. The biometric measures of palpebral fissure, the position of the eye/implant, and the condition of the cornea were evaluated during the follow-up period (12 months for eyelid and 18 for orbital injection). RESULTS In the course of the follow-up, all patients showed reliable reduction of lagophthalmos; additionally, improvement of the condition of the cornea was observed in patients after intrapalpebral injection; patients after intraorbital injection exhibited reduction in enophthalmos, upper orbital palpebral fold retraction and upper eyelid excursion. No serious complications have occurred after the injection. CONCLUSION As minimally invasive method of treating various pathologies of the orbit and eyelids, HAG fillers showed good clinical effectiveness and safety.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow Medical University, 8-2 Trubetskaya St., Moscow, Russian Federation, 119991
| | - V A Sheptulin
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
| | - J U Prause
- Eye Pathology Institute, University of Copenhagen, 10 Nørregade, Copenhagen, Denmark, 1165
| | - S S Danilov
- Research Institute of Eye Diseases, 11A Rossolimo St., Moscow, Russian Federation, 119021
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12
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Li K, Zhang XC, Cai XX, Quan YD, Lu R. The inflammation influence on corneal surface after frontalis suspension surgery. Int J Ophthalmol 2018; 11:1489-1495. [PMID: 30225223 DOI: 10.18240/ijo.2018.09.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/17/2018] [Indexed: 11/23/2022] Open
Abstract
AIM To study the influence of frontalis muscle flap suspension on ocular surface by analyzing the clinical features and inflammatory cytokines. METHODS A prospective, observational case series. Thirty-one eyes of 25 patients with severe congenital blepharoptosis who underwent frontalis muscle flap suspension surgery with at least 6mo of follow-up were included in the study. The main outcome measures were margin reflex distance 1 (MRD1), degree of lagophthalmos, ocular surface disease index (OSDI), fluorescein staining (Fl), tear break-up time (BUT), Schirmer I test, and inflammatory cytokine assay. RESULTS The degrees of lagophthalmos significantly increased after surgery. The OSDI scores significantly increased 1wk postoperatively and then decreased 4wk after operation. The Fl scores reflected corneal epithelial defects in sixteen patients at early stage postoperatively. The BUT and Schirmer I test values remained stable and did not show change compared to those before surgery. The inflammatory cytokines in conjunctival epithelial cells (including IL-1β, IL-6, IL-8, TNF-α, and IL-17A) significantly increased 1wk after the surgery (P<0.001), then returned to the normal level at 24wk postoperatively. The levels of inflammatory cytokine IL-1β, IL-6, IL-8, TNF-α, and IL-17A elevated significantly and were positively correlated with OSDI and Fl scores. CONCLUSION Frontalis muscle flap suspension surgery results in lagophthalmos in early period of post-operation and relieved after months. The elevation of inflammatory cytokines level may participate in the occurrence of corneal epithelial defects at the early postoperative stage.
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Affiliation(s)
- Kang Li
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Xin-Chun Zhang
- Department of Prosthodontics, Hospital of Stomatology, Guangdong Provincial Key Laboratory of Stomatology, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Xian-Xian Cai
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Ya-Dan Quan
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
| | - Rong Lu
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou 510060, Guangdong Province, China
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Fu R, Moore N, Shipchandler TZ, Ting JY, Tollefson T, Rabbani C, Moorthy M, Nunery WR, Harold Lee H. A hybrid technique to address exposure keratopathy secondary to facial nerve paresis: A combination of a lateral tarsorrhaphy and lateral wedge resection. Am J Otolaryngol 2018; 39:472-475. [PMID: 29776684 DOI: 10.1016/j.amjoto.2018.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 05/09/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To present the results of treating combined lower eyelid laxity, retraction and midface descent secondary to facial nerve weakness with a hybrid surgical procedure. MATERIALS AND METHODS A retrospective analysis of patients from January 2015 to January 2017 who underwent a hybrid surgical technique for the treatment of corneal exposure secondary to facial nerve paresis with a single surgeon was performed. Age, gender, and presence of exposure symptoms were recorded pre-operatively. Outcomes assessed included improvement of lower eyelid laxity and position, operative complications, and post-operative symptomatic relief. RESULTS A total of 11 patients underwent unilateral eyelid surgery. All patients had symptomatic relief and good functional outcomes defined as improvement in eyelid laxity, lower eyelid position, and objective corneal exposure. No cases required reoperation during an average follow up of 174.5 days. CONCLUSIONS Combining portions of a tarsorrhaphy and lateral wedge resection technique is a simple and effective procedure to improve lower eyelid position and limit corneal exposure secondary to facial nerve paresis.
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Abstract
PURPOSE OF REVIEW Periocular rehabilitation of the patient with a facial nerve palsy has evolved over time. Although protection of the ocular surface is paramount, application of disfiguring tarsorrhaphies should be utilized only in special situations. The purpose of this review is to discuss current surgical and medical strategies in treatment of the periocular area in patients with facial nerve palsy to give maximal functional and cosmetic results. RECENT FINDINGS Upper lid lagophthalmos is preferentially treated with upper eyelid weights. Platinum has distinct advantages over gold. A supratarsal position of the upper lid weight is preferred over a pretarsal location. Lower lid malposition should be treated as a retraction, rather than an ectropion. Recalcitrant ocular surface disease can be effectively managed with a scleral lens. Tearing in the patient with a facial nerve palsy is often multifactorial; small lumen Jones tubes and botulinum toxin injection to the lacrimal gland should be considered to treat epiphora in these patients. SUMMARY A facial nerve palsy can be devastating for patients from both a functional and cosmetic perspective. Although seismic shifts in treatment of the periocular subunit have not occurred, there are a number of small, yet significant, changes in treatment that should be adopted in taking care of these patients.
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Homer N, Fay A. Management of Long-Standing Flaccid Facial Palsy: Periocular Considerations. Otolaryngol Clin North Am 2018; 51:1107-1118. [PMID: 30170698 DOI: 10.1016/j.otc.2018.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ineffective eyelid closure can pose a serious risk of injury to the ocular surface and eye. In cases of eyelid paresis, systematic examination of the eye and ocular adnexa will direct appropriate interventions. Specifically, 4 distinct periorbital regions should be independently assessed: eyebrow, upper eyelid, ocular surface, and lower eyelid. Corneal exposure can lead to dehydration, thinning, scarring, infection, perforation, and blindness. Long-term sequelae following facial nerve palsy may also include epiphora, gustatory lacrimation, and synkinesis.
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Affiliation(s)
- Natalie Homer
- Department of Ophthalmology, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA; Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
| | - Aaron Fay
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA.
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16
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Reanimation of the paralyzed lids by cross-face nerve graft and platysma transfer. J Craniomaxillofac Surg 2018; 46:521-526. [DOI: 10.1016/j.jcms.2017.12.022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 10/27/2017] [Accepted: 12/18/2017] [Indexed: 11/23/2022] Open
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Wolkow N, Chodosh J, Freitag SK. Innovations in Treatment of Lagophthalmos and Exposure Keratopathy. Int Ophthalmol Clin 2017; 57:85-103. [PMID: 28885249 DOI: 10.1097/iio.0000000000000185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Leung VC, Belovay GW, Chan CC. TegadermTMdressing and Lacri-lube ointment moisture chamber to manage exposure keratopathy. Can J Ophthalmol 2016; 51:e149-e151. [DOI: 10.1016/j.jcjo.2016.05.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
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Application of Palpebral Spring in Asian Patients With Paralytic Lagophthalmos. Ophthalmic Plast Reconstr Surg 2016; 33:300-303. [PMID: 27564389 DOI: 10.1097/iop.0000000000000775] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Literature on palpebral springs is scarce, and even more so for the Asian population. In this study, the authors evaluated their experience with palpebral spring placement for paralytic lagophthalmos in an Asian population. The authors report the unique challenges encountered due to the distinctive features in Asian eyelids and how they overcome them. To the best of our knowledge, this is the first report on the application of palpebral springs in Asians. METHODS All patients treated for paralytic lagophthalmos in the Department of Surgery, Queen Mary Hospital, from November 2013 to December 2015, were included in this study. The authors retrieved and analyzed the demographic data, preoperative assessment details, and treatment outcomes. RESULTS A total of 17 patients were recruited. The median interval between facial palsy occurrence and surgery was 66 months. Preoperatively, vertical palpebral fissure was 12.3 ± 1.7 mm with margin reflex distance 1 of 3.7 ± 0.3 mm and margin reflex distance 2 of 8.6 ± 1.6 mm. Lagophthalmos before surgery was 9.6 ± 2.3 mm. After the palpebral spring surgeries, vertical palpebral fissure was reduced to 9.1 ± 1.4 mm. margin reflex distance 1 is slightly reduced (3.3 ± 0.8 mm) and margin reflex distance 2 improved to 5.8 ± 1.0 mm. Lagophthalmos reduced significantly to 0.8 ± 1.3 mm. Seven patients required revision procedures. CONCLUSIONS Palpebral spring is a safe and effective treatment for Asian patients with paralytic lagophthalmos. However, surgeons should be aware of the unique challenges associated with the anatomy of Asian eyelids. Special adaptation of the procedure is required to optimize the outcome.
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Grusha YO, Fedorov AA, Iskusnykh NS, Bogacheva NV, Kobzova MV, Novikov IA, Fettser EI, Shchegoleva TA. [Gold weight implants for lagophthalmos correction in chronic facial nerve paralysis (late results)]. Vestn Oftalmol 2016; 132:26-32. [PMID: 27213794 DOI: 10.17116/oftalma2016132226-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Upper eyelid weigh gold implant is the widely accepted standard for the treatment of paralytic lagophthalmos (PL). AIM To evaluate late outcomes of PL correction with chain gold implants. MATERIAL AND METHODS Chain gold implants were inserted in the upper eyelids of 70 patients with lagophthalmos due to chronic facial paralysis. A comprehensive ophthalmic examination was performed prior to surgery and then at months 1, 3, 6, 12, 24, and 36. RESULTS The results obtained prove the method highly effective. None of the patients developed any severe complications. Cases of implant removal were few. Some of the studied biometric parameters decreased significantly after surgery, while the upper eyelid excursion increased. The implant had no effect on the inner surface of the cornea and its peripheral thickness. CONCLUSION Efficacy of the proposed eyelid implant has been convincingly demonstrated; late complications have been analyzed.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, Ophthalmology Department, 2 str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - A A Fedorov
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
| | - N S Iskusnykh
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
| | - N V Bogacheva
- Lomonosov Moscow State University, Faculty of Psychology, 1 Leninskie Gory, Moscow, Russian Federation, 119991
| | - M V Kobzova
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, Ophthalmology Department, 2 str. 4 Bol'shaya Pirogovskaya St., Moscow, Russian Federation, 119991
| | - I A Novikov
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
| | - E I Fettser
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
| | - T A Shchegoleva
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
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Abstract
Facial nerve paralysis is a devastating condition arising from several causes with severe functional and psychological consequences. Given the complexity of the disease process, management involves a multispecialty, team-oriented approach. This article provides a systematic approach in addressing each specific sequela of this complex problem.
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Affiliation(s)
- Ali Razfar
- Division of Facial Plastic and Reconstructive Surgery, Center for Facial Cosmetic Surgery, University of Michigan School of Medicine, 19900 Haggerty Hwy, Livonia, MI 48152, USA
| | - Matthew K Lee
- Division of Facial Plastic and Reconstructive Surgery, Stanford University School of Medicine, 801 Welch Rd, Palo Alto, CA, 94305 USA
| | - Guy G Massry
- Ophthalmic Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, 9401 Wilshire Blvd., Suite 650, Beverly Hills, CA 90212, USA
| | - Babak Azizzadeh
- Department of Head and Neck Surgery, Center for Advanced Facial Plastic Surgery, David Geffen School of Medicine, University of California, Los Angeles, 9401 Wilshire Blvd., Suite 650, Beverly Hills, CA 90212, USA.
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Wambier SPF, Garcia DM, Cruz AAV, Messias A. Spontaneous Blinking Kinetics on Paralytic Lagophthalmos After Lid Load with Gold Weight or Autogenous Temporalis Fascia Sling. Curr Eye Res 2015; 41:433-40. [PMID: 26016510 DOI: 10.3109/02713683.2015.1031252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To assess the upper eyelid kinematics during spontaneous blinking in unilateral paralytic lagophthalmos before and after upper eyelid load with gold weight (GW) or autogenous temporalis fascia (TF) sling. DESIGN Comparative case series. SUBJECTS Patients with long-standing unresolved unilateral facial palsy who underwent surgical treatment with GW (n = 8) or upper lid cerclage with TF (n = 10). The contralateral eyelid served as the control for each patient (control group). METHODS Preoperative and postoperative measurements of spontaneous blink kinematics with magnetic search coil and clinical assessment of lid margin position, lagophthalmos and ocular surface exposure, and determine amplitude, maximum velocity and main sequence of spontaneous blinks; relative amplitude of blinks to the pupil center; ocular surface exposure scores; magnitude of lagophthalmos and mid-pupil lid distances. RESULTS The mean (±SE) down-phase amplitude ratio between paralyzed and contralateral eyelids (blink gain) was 10.0% preoperatively for both groups and significantly increased to 29 ± 6% for the GW group (p < 0.05) and 23 ± 4% for the TF group (p < 0.05). At 6 months the gain was significant for the GW group only (32 ± 7%, p < 0.05). There was no effect on the maximum velocity of the blinks or the main sequence of paretic and contralateral blinks with either surgery. Both procedures lowered the lid margin increasing the number of blinks that reached the pupil center. At 6 months this effect was prominent only for the GW group. Exposure keratopathy scores and lagophthalmos decreased postoperatively especially in the GW group. CONCLUSIONS The beneficial effect of lid load surgeries result from a combination of a small increase on the spontaneous blink amplitude and a static effect due to the reduction of the distance between the lid margin and pupil center.
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Affiliation(s)
- Sarah P F Wambier
- a Department of Ophthalmology , Otorhinolaryngology, Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo , Sao Paulo , Brazil and
| | - Denny M Garcia
- a Department of Ophthalmology , Otorhinolaryngology, Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo , Sao Paulo , Brazil and.,b Craniofacial Research Support Center, University of São Paulo , Sao Paulo , Brazil
| | - Antonio A V Cruz
- a Department of Ophthalmology , Otorhinolaryngology, Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo , Sao Paulo , Brazil and.,b Craniofacial Research Support Center, University of São Paulo , Sao Paulo , Brazil
| | - Andre Messias
- a Department of Ophthalmology , Otorhinolaryngology, Head and Neck Surgery, Ribeirão Preto Medical School, University of São Paulo , Sao Paulo , Brazil and
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Abstract
Current options for correction of paralytic lagophthalmos are either temporary (external eyelid weight placement, hyaluronic acid gel or botulinum toxin A injection) or permanent (various procedures for narrowing of the palpebral fissure, upper eyelid weights or spring implantation). Neuroplastic surgery (cross-facial nerve grafting, nerve anastomoses) and muscle transposition surgery is not effective enough. The majority of elderly and medically compromised patients should not be considered for such complicated and long procedures. Upper eyelid weight implantation thus appears the most reliable and simple treatment.
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Affiliation(s)
- N S Iskusnykh
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021
| | - Y O Grusha
- Research Institute of Eye Diseases, 11 A, B Rossolimo St., Moscow, Russian Federation, 119021; I.M. Sechenov First Moscow State Medical University, Chair of Eye Diseases, Bolshaya Pirogovskaya St. 2-4, Moscow, Russian Federation, 119991
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Portelinha J, Passarinho MP, Costa JM. Neuro-ophthalmological approach to facial nerve palsy. Saudi J Ophthalmol 2014; 29:39-47. [PMID: 25859138 DOI: 10.1016/j.sjopt.2014.09.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022] Open
Abstract
Facial nerve palsy is associated with significant morbidity and can have different etiologies. The most common causes are Bell's palsy, Ramsay-Hunt syndrome and trauma, including surgical trauma. Incidence varies between 17 and 35 cases per 100,000. Initial evaluation should include accurate clinical history, followed by a comprehensive investigation of the head and neck, including ophthalmological, otological, oral and neurological examination, to exclude secondary causes. Routine laboratory testing and diagnostic imaging is not indicated in patients with new-onset Bell's palsy, but should be performed in patients with risk factors, atypical cases or in any case without resolution within 4 months. Many factors are involved in determining the appropriate treatment of these patients: the underlying cause, expected duration of nerve dysfunction, anatomical manifestations, severity of symptoms and objective clinical findings. Systemic steroids should be offered to patients with new-onset Bell's palsy to increase the chance of facial nerve recovery and reduce synkinesis. Ophthalmologists play a pivotal role in the multidisciplinary team involved in the evaluation and rehabilitation of these patients. In the acute phase, the main priority should be to ensure adequate corneal protection. Treatment depends on the degree of nerve lesion and on the risk of the corneal damage based on the amount of lagophthalmos, the quality of Bell's phenomenon, the presence or absence of corneal sensitivity and the degree of lid retraction. The main therapy is intensive lubrication. Other treatments include: taping the eyelid overnight, botulinum toxin injection, tarsorrhaphy, eyelid weight implants, scleral contact lenses and palpebral spring. Once the cornea is protected, longer term planning for eyelid and facial rehabilitation may take place. Spontaneous complete recovery of Bell's palsy occurs in up to 70% of cases. Long-term complications include aberrant regeneration with synkinesis. FNP after acoustic neuroma surgery remains the most common indication for FN rehabilitation.
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Affiliation(s)
- Joana Portelinha
- Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | | | - João Marques Costa
- Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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Lateral Tarsoconjunctival Onlay Flap Lower Eyelid Suspension in Facial Nerve Paresis. Ophthalmic Plast Reconstr Surg 2014; 30:342-5. [DOI: 10.1097/iop.0000000000000175] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Colbert S, Coombes D, Godden D, Cascarini L, Kerawala C, Brennan PA. How do I manage an acute injury to the facial nerve? Br J Oral Maxillofac Surg 2014; 52:67-71. [DOI: 10.1016/j.bjoms.2013.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 09/02/2013] [Indexed: 11/25/2022]
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Ginat DT, Bhama P, Cunnane ME, Hadlock TA. Facial reanimation procedures depicted on radiologic imaging. AJNR Am J Neuroradiol 2013; 35:1662-6. [PMID: 23945230 DOI: 10.3174/ajnr.a3684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Various facial reanimation procedures can be performed for treating patients with chronic facial nerve paralysis. The radiologic imaging features of static and dynamic techniques are reviewed in this article with clinical correlation, including brow lift, eyelid weights and springs, gracilis free flaps, fascia lata grafts, temporalis flaps, and Gore-Tex suspension slings. Although the anatomic alterations resulting from facial reanimation surgery may not necessarily be the focus of the imaging examination, it is important to recognize such changes and be familiar with MR imaging compatibility of the associated implanted materials. Furthermore, imaging is sometimes used to specifically evaluate the postoperative results, such as vessel patency following free gracilis transfer.
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Affiliation(s)
- D T Ginat
- From the Department of Radiology (D.T.G.), Division of Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts
| | - P Bhama
- Department of Otolaryngology (P.B., T.A.H.), Division of Facial Plastic and Reconstructive Surgery
| | - M E Cunnane
- Department of Radiology (M.E.C.), Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - T A Hadlock
- Department of Otolaryngology (P.B., T.A.H.), Division of Facial Plastic and Reconstructive Surgery
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Treatment of refractory exposure keratitis with modified medial tarsorrhaphy using tarsoconjunctival flap. Graefes Arch Clin Exp Ophthalmol 2012; 251:1369-72. [DOI: 10.1007/s00417-012-2238-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Revised: 11/18/2012] [Accepted: 12/03/2012] [Indexed: 10/27/2022] Open
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Abstract
PURPOSE Surgical treatment of myogenic ptosis usually requires a form of frontalis suspension. Complications can include entropion, headache, contour abnormalities, and poor eyelid excursion. The Levine palpebral spring has been used successfully to augment eyelid closure in more than 2,000 patients. The authors present a modified Levine spring to correct ptosis in a patient with poor levator function. METHODS Interventional case report. A 55-year-old man with profound myogenic ptosis was treated with bilateral modified Levine palpebral springs. Eyelid position, contour and excursion, blink reflex, lagophthalmos, and ocular surface were evaluated. RESULTS The Levine palpebral spring functioned well to open both eyelids. Margin reflex distance improved from -3 mm to 3 m postoperatively. Excellent contour and excursion were observed. Orbicularis action, including blink reflex, was preserved, and ocular surface was not compromised. CONCLUSION The modified Levine palpebral spring is an alternative to frontalis suspension in treating select patients with eyelid ptosis with poor levator function.
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Militsakh ON, Sanderson JA, Lin D, Wax MK. Rehabilitation of a parotidectomy patient-A systematic approach. Head Neck 2012; 35:1349-61. [DOI: 10.1002/hed.23095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2012] [Indexed: 11/10/2022] Open
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Abstract
Background Reconstructive surgery of the facial nerve is not daily routine for most head and neck surgeons. The published experience on strategies to ensure optimal functional results for the patients are based on small case series with a large variety of surgical techniques. On this background it is worthwhile to develop a standardized approach for diagnosis and treatment of patients asking for facial rehabilitation. Conclusion A standardized approach is feasible: Patients with chronic facial palsy first need an exact classification of the palsy's aetiology. A step-by-step clinical examination, if necessary MRI imaging and electromyographic examination allow a classification of the palsy's aetiology as well as the determination of the severity of the palsy and the functional deficits. Considering the patient's desire, age and life expectancy, an individual surgical concept is applicable using three main approaches: a) early extratemporal reconstruction, b) early reconstruction of proximal lesions if extratemporal reconstruction is not possible, c) late reconstruction or in cases of congenital palsy. Twelve to 24 months after the last step of surgical reconstruction a standardized evaluation of the therapeutic results is recommended to evaluate the necessity for adjuvant surgical procedures or other adjuvant procedures, e.g. botulinum toxin application. Up to now controlled trials on the value of physiotherapy and other adjuvant measures are missing to give recommendation for optimal application of adjuvant therapies.
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Re: "Palpebral spring in the management of lagophthalmos and exposure keratopathy secondary to facial nerve palsy". Ophthalmic Plast Reconstr Surg 2010; 26:499-500. [PMID: 20639787 DOI: 10.1097/iop.0b013e3181cc872e] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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