Effectiveness of the lower eyelid suspension using fascia lata graft for the treatment of lagophthalmos due to facial paralysis

Enhancing Lower Eyelid Suspension Outcomes Through Pre-surgical Facial Nerve Reanimation: A Comparative Study

BACKGROUND

Lower eyelid suspension, a common therapeutic procedure for facial paralysis-induced eyelid retraction, faces challenges due to high recurrence in patients lacking facial muscle function and impedes wider adoption. This research aims to explore the potential effects of restoring orbicularis oculi muscle tension through facial nerve reanimation prior to lower eyelid suspension and to define the indications for lower eyelid suspension.

METHODS

The study encompassed 32 individuals with complete facial paralysis, segmented into group A (reanimation group) and group B (non-reanimation group), based on whether the orbicularis oculi muscle's tension was restored through facial nerve reconstruction prior to lower eyelid suspension. Subjective assessments of eyelid closure (the inter-eyelid gap upon gentle closure) and objective methods measures of scleral show (the distance from the pupil's center to the lower eyelid margin, MRD2) were used to provide a comprehensive analysis of long-term effectiveness.

RESULTS

The group A exhibited significantly greater long-term improvement in lagophthalmos and lower eyelid ectropion. The alterations in MRD2 measured 2.66 ± 0.27 mm in the group A versus 2.08 ± 0.53 mm in the group B, denoting a statistically significant variance (p < 0.001). Moreover, while the ratio of MRD2 preoperative 6 months postoperative revealed no significant difference between groups, a significant difference emerged in 12 months postoperative (group A: 1.02 ± 0.21; group B: 1.18 ± 0.24; p < 0.05), with the values in group A closer to 1, indicative of enhanced symmetry.

CONCLUSIONS

Restoring the tension in the orbicularis oculi muscle through facial nerve reconstruction prior to palmaris longus tendon sling could effectively sustain long-term outcomes of lower eyelid retraction correction and reduce the recurrence rate.

LEVEL OF EVIDENCE IV

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Lateral Tarsal Strip versus Tensor Fascia Lata Sling for Paralytic Ectropion: Comparison and Long-Term Outcomes

BACKGROUND

Paralytic ectropion increases risk for corneal injury in facial palsy patients. Although a lateral tarsal strip (LTS) provides corneal coverage through superolateral lower eyelid pull, the unopposed lateral force may result in lateral displacement of the lower eyelid punctum and overall worsening asymmetry. A tensor fascia lata (TFL) lower eyelid sling may overcome some of these limitations. This study quantitatively compares scleral show, punctum deviation, lower marginal reflex distance, and periorbital symmetry between the two techniques.

METHODS

Retrospective review was performed on facial paralysis patients who underwent LTS or TFL sling surgery with no prior lower lid suspension procedures. Standardized preoperative and postoperative images in primary gaze position were used to measure scleral show and lower punctum deviation using ImageJ, and lower marginal reflex distance using Emotrics.

RESULTS

Of 449 facial paralysis patients, 79 met inclusion criteria. Fifty-seven underwent LTS surgery and 22 underwent TFL sling surgery. Compared with preoperatively, lower medial scleral show improved significantly with both LTS (10.9 mm 2 ; P < 0.01) and TFL (14.7 mm 2 ; P < 0.01). The LTS group showed significant worsening of horizontal and vertical lower punctum deviation when compared with the TFL group (both P < 0.01). The LTS group was unable to achieve periorbital symmetry between the healthy and paralytic eye across all parameters measured postoperatively ( P < 0.01); and the TFL group achieved symmetry in medial scleral show, lateral scleral show, and lower punctum deviation.

CONCLUSION

In patients with paralytic ectropion, TFL sling provides similar outcomes to LTS, with the added advantages of symmetry without lateralization or caudalization of the lower medial punctum.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Efficacy of allogenous fascia lata grafts in the management of lower eyelid retraction

PURPOSE

To report on the use of allogenous fascia lata (FL) grafts in patients with lower eyelid retraction (LER).

METHODS

In this retrospective study, a consecutive series of 27 patients (39 eyes) with LER who underwent lower eyelid elevation with FL was included. Examinations including measurement of the palpebral fissure vertical height (PFVH), the inferior scleral show distance, the margin reflex distance 2 (MRD 2), and the evaluation of conjunctival hyperemia were conducted at baseline and after a mean postoperative time of 25.9 ± 25.5 (5.0-81.0, median 13.0, last follow-up) months in all patients.

RESULTS

At the last follow-up, a significant reduction of the PFVH (11.3 ± 1.7 versus 12.8 ± 2.1 at baseline, p < 0.001), the inferior scleral show distance (0.7 ± 1.0 mm versus 2.1 ± 1.1 at baseline, p < 0.001), and the MRD 2 (6.4 ± 0.9 versus 7.8 ± 1.3 at baseline, p < 0.001) occurred. The conjunctival hyperemia grading score (McMonnies) was significantly reduced (1.8 ± 0.7) at the last follow-up compared to baseline (2.6 ± 0.6, p < 0.001). No case of ectropion or entropion was observed at the last follow-up visit.

CONCLUSION

In this case series, lower eyelid elevation with FL grafts as a spacer led to a significant reduction of the PFVH, MRD 2, inferior scleral show distance, and conjunctival hyperemia. No severe surgery-related complications occurred.

Lower Eyelid Sling for Primary and Revision Correction of Paralytic Lagophthalmos

Background: Lateral tarsal techniques alone for lower eyelid correction in paralytic lagophthalmos may yield suboptimal outcomes. Objective: To describe a lower eyelid sling technique for primary and revision correction of lower eyelid ptosis and ectropion and evaluate outcomes as measured by margin reflex distance 2 (MRD2). Methods: A retrospective review of patients with long-standing unilateral paralytic lagophthalmos who underwent primary or revision lower eyelid ptosis correction by sling suspension between January 2016 and August 2020 at a tertiary medical center was performed. Surgical technique is illustrated with video and technical considerations are discussed. Pre- and postoperative MRD2 values were quantified from databased photographs. Results: Thirty-eight patients were included. Eighteen patients had undergone prior procedures for ptosis correction. Lower eyelid symmetry and paralyzed side MRD2 significantly improved after lower lid sling for primary and revision cases (p < 0.05), and improvement was sustained over the study period (mean follow-up duration 13.3 months, range 1-33 months). No postoperative complications occurred. Conclusion: Lower eyelid sling yielded safe, effective, and durable correction of lower eyelid position in a cohort of patients with paralytic lagophthalmos.

Lower Eyelid Management in Facial Paralysis

Correction of lower eyelid retraction is necessary to restore adequate blink in paralytic lagophthalmos. A plethora of static and dynamic surgical techniques have been described for lower eyelid repositioning. This article provides an approach to management of the paralytic lower eyelid, including a summary of existing techniques, case examples, and surgical technique for in-office lower eyelid suspension using a palmaris longus tendon graft.

An anatomical appraisal of dynamic muscle transfer of the orbicularis oculi muscle

Facial nerve palsy can cause significant distress for patients. We investigated the innervation of the orbicularis oculi muscle (OOM) and assessed the viability of unipedicle contralateral muscle transfer to restore symmetrical and spontaneous blinking. Cadaveric dissection and measurements were performed on lite fixed cadavers (n = 15). Medial innervation of the OOM was identified prior to raising and transposing a flap to the contralateral eyelid. Measurements were performed in-situ and following transposition. A medial ascending branch of the buccal nerve innervating the OOM was identified bilaterally in all cadavers. The average length of flap raised was 59.85 mm (± 4.69 mm) with no difference between the left and right. Flaps with pedicles not dissected off the bone covered 48% of the ciliary margin length (CM) and 62% of the palpebral length (PL). Flaps dissected off the bone covered 72% of the CM and 92% of the PL. The results demonstrate that a flap can theoretically transpose to >50% of the contralateral eyelid length. Increased coverage of the eyelid was achieved by releasing the pedicle from the underlying bone. Little attention was focused on buccal innervation of the eyelids, and this consistent medial pattern may allow an innervated flap transfer to restore symmetrical blinking, something that eludes modern paralysis surgery in a single-stage procedure.

The Use of Fascia Lata Free Graft for Lateral Canthus Reconstruction Following Mohs Lower Lid Surgery

We present a case of a 75-year-old patient who underwent reconstruction of the lower eyelid and lateral canthus following removal of 80% of the lower eyelid due to basal cell carcinoma. A Hughes transconjunctival eyelid-sharing flap was used to form the posterior lamella, and a free skin graft from the ipsilateral upper lid was used to recreate the anterior lamella. The lateral canthal ligament was reconstructed using a free fascia lata graft. A periosteal flap was not used due to local scarring that was the result of previous multiple lateral canthal surgeries. Skin preservation in the lateral canthal area and additional horizontal support for the lower eyelid were achieved by using a local advancement flap. This two-stage surgery produced excellent functional and cosmetic effects. Fascia lata free graft can be an alternative to the periosteal flap for reconstruction of the lateral canthal ligament when use of the lateral orbital periosteum is not feasible.

Pediatric facial reanimation: An algorithmic approach and systematic review

Facial palsy has a broad clinical presentation and the effects on psychosocial interaction and facial functions can be devastating. Pediatric facial palsy, in particular, introduces unique familial and technical considerations as anatomy, future growth potential, and patient participation influence treatment planning. Though some etiologies of pediatric facial palsy are self-limiting, congenital and long-standing facial palsies pose difficult challenges that require a combination of surgical, adjunctive, and rehabilitative techniques to achieve facial reanimation. Given the spectrum of ages and symptom severity, as well as the various surgical options available for facial palsy, a tailored approach needs to be developed for each child to restore facial balance and function. Here, we review the etiologies, workup, and treatment of pediatric facial palsy and present our novel algorithmic approach to treatment.

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.

Outcomes of lower eyelid retractor recession and lateral horn lysis in lower eyelid elevation for facial nerve palsy

PurposeTo report outcomes and complications of lower eyelid retractor recession and lateral horn lysis (RR) for lower eyelid elevation in patients with facial nerve palsy (FNP).Patients and methodsRetrospective review. Patients with FNP undergoing RR alone (group 1) or with adjunctive procedures (canthal suspension-group 2, tarsorrhaphy-group 3, and full-thickness skin graft-group 4) during a 5-year period were included. Patient demographics, lagophthalmos, occurrence of eyelid malpositions, recurrent retraction, and repeat procedures were noted from medical records. Measures of lower eyelid height (LEH) and lid lag on downgaze were obtained from standard photographs.ResultsForty-two patients (23 females, mean age was 59 years) were included. Mean follow-up was 24 months (range 6-77). Median improvement in LEH following surgery was significant in Group 1 (0.90 mm, IQR: 0.37-0.91, P=0.20) and in Group 2 (0.51 mm, IQR: 0.30-1.37, P<0.001), respectively. Median improvement in blink lagophthalmos was 3.00 mm (IQR: 3.00-3.50, P=0.02) in Group 1 and 3.50 mm (IQR: 1.75-5.00, P<0.001) in Group 2. Median improvement in lagophthalmos on gentle eye closure was 2.00 mm (IQR: 1.50-3.00, P=0.02) in Group 1 and 1.00 mm (IQR: 0-2.13, P=0.006) in Group 2. No new cases of ectropion were noted. 23.5% of patients required a repeat RR at a mean interval of 20 (range 1-70) months and a further 9.8% required a third procedure at a mean interval of 21 (range 18-29) months.ConclusionRR improves lower eyelid retraction and lagophthalmos in FNP either alone or when combined as an adjunctive procedure. It does not aggravate paralytic ectropion although repeated retractor recessions may be required to improve retraction.