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

A Magnetic Actuator Device for Fully Automated Blinking in Total Bidirectional Eyelid Paralysis: First Proof of Concept in a Human Participant

Purpose

Currently, no solution exists to restore natural eyelid kinematics for patients with complete eyelid paralysis due to loss of function of both the levator palpebrae superioris and orbicularis oculi. These rare cases are prone to complications of chronic exposure keratopathy which may lead to corneal blindness. We hypothesized that magnetic force could be used to fully automate eyelid movement in these cases through the use of eyelid-attached magnets and a spectacle-mounted magnet driven by a programmable motor (motorized magnetic levator prosthesis [MMLP]).

Methods

To test this hypothesis and establish proof of concept, we performed a finite element analysis (FEA) for a prototype MMLP to check the eyelid-opening force generated by the device and verified the results with experimental measurements in a volunteer with total bidirectional eyelid paralysis. The subject was then fitted with a prototype to check the performance of the device and its success.

Results

With MMLP, eye opening was restored to near normal, and blinking was fully automated in close synchrony with the motor-driven polarity reversal, with full closure on the blink. The device was well tolerated, and the participant was pleased with the comfort and performance.

Conclusions

FEA simulation results conformed to the experimentally observed trend, further supporting the proof of concept and design parameters. This is the first viable approach in human patients with proof of concept for complete reanimation of a bidirectionally paretic eyelid. Further study is warranted to refine the prototype and determine the feasibility and safety of prolonged use.

Translational Relevance

This is first proof of concept for our device for total bidirectional eyelid paralysis.

Development of an implantable bionic for dynamic eye closure in facial nerve paralysis: Evolution of the design

Facial nerve paralysis (FNP) presents with a constellation of clinical problems but its most concerning consequence is corneal exposure from lack of blinking. Bionic lid implant for natural closure (BLINC) is an implantable solution for dynamic eye closure in FNP. It uses an electromagnetic actuator to mobilise the dysfunctional eyelid by means of an eyelid sling. This study highlights issues relating to device biocompatibility and describes its evolution to overcome some of these issues. The essential components of the device are the actuator, the electronics including energy storage, and an induction link for wireless power transfer. Effective arrangement of these components within the anatomical confines and their integration is achieved through a series of prototypes. The response of each prototype is tested in a synthetic or cadaveric model for eye closure with the final prototype designed for acute and chronic animal trials.

Facial nerve paralysis: A review on the evolution of implantable prosthesis in restoring dynamic eye closure

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.

Recreation of eyelid mechanics using the sling concept✰

BACKGROUND

Paralytic lagophthalmos causes major functional, aesthetic and psychological problems in patients with facial paralysis. The Bionic Lid Implant for Natural Closure (BLINC) project aims to restore eyelid function using an implanted electromagnetic actuator combined with an eyelid sling. The authors performed a preliminary study using cadaveric heads to investigate the optimal application of an eyelid sling in various configurations around the orbit.

METHODS

The sling was tested in a cadaveric sheep head using 2 medial anchor points and 4 lateral ostectomy points. An impulse was generated using gravitational force to test each combination of medial and lateral sling insertion sites using weights between 10 and 50 g. Each generated blink was recorded and analysed. The final result was validated in a human cadaveric model.

RESULTS

The maximum amount of eye closure and closure speed displayed in sheep were 83.7 ± 9.4% of total closure and 70.6 ± 6.9 mm/s at a maximum force of 490 mN, respectively. The 2 inferior lateral attachments performed better at displacing the eyelid than the superior attachments. The position with the highest degree of eye-closure (improvement of 21.6%, p < 0.001) and speed (improvement of 30.4 mm/s, p < 0.001) was the combination of a posterior medial attachment and an inferior-posterior lateral attachment, which resulted in a near physiological closure in human cadaver.

CONCLUSION

Closure improved with an inferior lateral position due to increased force acting in the direction of closure. Posterior positioning increases force acting radially, towards the centre of eyelid movement. The latter directs the closure force to effectively move the eyelid around the curved globe.

Update in facial nerve paralysis: tissue engineering and new technologies

PURPOSE OF REVIEW

To present the recent advances in the treatment of facial paralysis, emphasizing the emerging technologies. This review will summarize the current state of the art in the management of facial paralysis and discuss the advances in nerve regeneration, facial reanimation, and use of novel biomaterials. This review includes surgical innovations in reinnervation and reanimation as well as progress with bioelectrical interfaces.

RECENT FINDINGS

The last decade has witnessed major advances in the understanding of nerve injury and approaches for management. Key innovations include strategies to accelerate nerve regeneration, provide tissue-engineered constructs that may replace nonfunctional nerves, approaches to influence axonal guidance, limiting of donor-site morbidity, and optimization of functional outcomes. Approaches to muscle transfer continue to evolve, and new technologies allow for electrical nerve stimulation and use of artificial tissues.

SUMMARY

The fields of biomedical engineering and facial reanimation increasingly intersect, with innovative surgical approaches complementing a growing array of tissue engineering tools. The goal of treatment remains the predictable restoration of natural facial movement, with acceptable morbidity and long-term stability. Advances in bioelectrical interfaces and nanotechnology hold promise for widening the window for successful treatment intervention and for restoring both lost neural inputs and muscle function.

Dynamic facial prosthetics for sufferers of facial paralysis

BACKGROUND

This paper discusses the various methods and the materials for the fabrication of active artificial facial muscles. The primary use for these will be the reanimation of paralysed or atrophied muscles in sufferers of non-recoverable unilateral facial paralysis.

METHOD

The prosthetic solution described in this paper is based on sensing muscle motion of the contralateral healthy muscles and replicating that motion across a patient's paralysed side of the face, via solid state and thin film actuators. The development of this facial prosthetic device focused on recreating a varying intensity smile, with emphasis on timing, displacement and the appearance of the wrinkles and folds that commonly appear around the nose and eyes during the expression. An animatronic face was constructed with actuations being made to a silicone representation musculature, using multiple shape-memory alloy cascades. Alongside the artificial muscle physical prototype, a facial expression recognition software system was constructed. This forms the basis of an automated calibration and reconfiguration system for the artificial muscles following implantation, so as to suit the implantee's unique physiognomy.

RESULTS

An animatronic model face with silicone musculature was designed and built to evaluate the performance of Shape Memory Alloy artificial muscles, their power control circuitry and software control systems. A dual facial motion sensing system was designed to allow real time control over model - a piezoresistive flex sensor to measure physical motion, and a computer vision system to evaluate real to artificial muscle performance. Analysis of various facial expressions in real subjects was made, which give useful data upon which to base the systems parameter limits.

CONCLUSION

The system performed well, and the various strengths and shortcomings of the materials and methods are reviewed and considered for the next research phase, when new polymer based artificial muscles are constructed and evaluated.

A closed-loop stimulation system supplemented with motoneurone dynamic sensitivity replicates natural eye blinks

OBJECTIVE

The authors are designing an implantable device that will electrically stimulate a paretic eyelid when electrodes implanted into the contralateral healthy orbicularis oculi muscle detect a spontaneous blink activity. As a novelty, the stimulation pattern includes the dynamic sensitivity of motor units, thus obtaining complete eyelid closure, tailored on the kinematics of the natural eye blink.

STUDY DESIGN

A preliminary study was performed on 10 healthy subjects, to observe, first, the kinematics of their natural eye blink and, second, the eye blink stimulated by a dynamic vs nondynamic pattern.

SETTING

A microaccelerometer taped onto the left upper eyelid detected its kinematics. A dedicated LabView software built up and triggered the stimulation pattern. A webcam recorded the behavioral effect.

SUBJECTS AND METHODS

The kinematics of spontaneous eye blinks was detected. Then, an epicutaneous stimulation of the facial nerve branch for the left orbicularis oculi muscle was performed on the same subjects. Muscle recruitment curves were studied, and acceleration of the bionic blink was measured and compared with the natural one.

RESULTS

Kinematics of the natural eyelid is highly variable within subjects. The stimulation pattern frequency was set case by case in order to obtain the desired eyelid acceleration of the contralateral eye. A custom-fit dynamic stimulation leads to a symmetrical natural-like eye blink.

CONCLUSIONS

By adding the dynamic pulse, the authors were able to tailor a bionic eye blink, which was hardly distinguishable from the subject's natural one.

The effect of Teflon coating on the resistance to sliding of orthodontic archwires

Teflon is an anti-adherent and aesthetic material. The aim of this study was to evaluate, in vitro, the influence of Teflon coating on the resistance to sliding (RS) of orthodontic archwires. For this purpose, Teflon-coated archwires were examined using frictional resistance tests by means of a universal testing machine and compared with conventional uncoated wires. Twelve types of archwires with round and rectangular sections (0.014, 0.018, and 0.018 × 0.025 inches) and of different materials (stainless steel and nickel-titanium) were tested with two passive self-ligating brackets (SmartClip™ and Opal(®)) and one active self-ligating bracket (Quick(®)). Each archwire-bracket combination was tested 10 times under 8 simulated clinical scenarios. Statistical comparisons were conducted between the uncoated and Teflon-coated archwires using Wilcoxon and Mann-Whitney tests, and linear regression analysis. For all bracket-archwire combinations, Teflon-coated archwires resulted lower friction than the corresponding uncoated archwires (P < 0.01). The results showed that Teflon coating has the potential to reduce RS of orthodontic archwires.