Autologous dermis graft versus conchal cartilage graft for managing lower eyelid retraction: A comparative study

Reanimation Techniques of Peripheral Facial Paralysis: A Comprehensive Review Focusing on Surgical and Bioengineering Approaches

Peripheral facial paralysis represents a disabling condition with serious psychological and social impact. Patients with peripheral facial paralysis have a disfigurement of the face with loss of harmony and symmetry and difficulties in everyday facial functions such as speaking, drinking, laughing, and closing their eyes, with impairment of their quality of life. This paralysis leads to impairment of facial expression, which represents one of the first means of communication, an important aspect of human interaction. This review aims to explore the reanimation techniques for managing peripheral facial paralysis. An analysis of static and dynamic techniques for facial reanimation is provided, including muscle flaps, nerve grafting techniques, and bioengineering solutions. Each technique showed its benefits and drawbacks; despite several options for facial reanimation, no technique has been detected as the gold standard. Therefore, each patient must be evaluated on an individual basis, considering their medical history, age, expectations, and treatment goals, to find the best and most fitting treatment.

Revisiting the Use of Deep Temporalis Fascia Grafts in Ophthalmology

PURPOSE

To report new indications for deep temporalis fascia (DTF) grafts in the ophthalmic field.

METHODS

Monocentric retrospective interventional case series study. All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020-October 2023) were included. For each patient, gender, age, graft indication, outcomes, complications, and follow-up duration were collected. In most cases, the DTF graft was covered by a vascularized flap.

RESULTS

Eight patients underwent a DTF graft over the study period. The indications were: radiotherapy-induced scleral necrosis in three cases, tendinoplasty to replace the inferior rectus muscle tendon invaded by a locally advanced conjunctival carcinoma in one case, Ahmed glaucoma valve tube exposure in one case, intraocular lens with scleral fixation exposure in one case, orbital cerebrospinal fluid fistula (orbitorrhea) in one case, and post-traumatic complete corneal graft loss in one case. The DTF graft was successful in 87.5% of cases after a mean follow-up of 11.4 months. No complications were observed.

CONCLUSIONS

DTF graft is a highly versatile graft that can be easily harvested. New indications for DTF grafts may include the repair of radiotherapy-induced scleral necrosis, the creation of oculomotor tendon and the temporary packing of large ocular tissue loss in an emergency context. Further studies with a longer follow-up are needed to confirm our preliminary results.

Bioengineering autologous cartilage grafts for functional posterior lamellar eyelid reconstruction: A preliminary study in rabbits

The reconstruction of posterior lamellar eyelid defects remains a significant challenge in clinical practice due to anatomical complexity, specialized function, and aesthetic concerns. The ideal substitute for the posterior lamellar should replicate the native tarsoconjunctival tissue, providing both mechanical support for the eyelids and a smooth surface for the globe after implantation. In this study, we present an innovative approach utilizing tissue-engineered cartilage (TEC) grafts generated from rabbit auricular chondrocytes and a commercialized type I collagen sponge to reconstruct critical-sized posterior lamellar defects in rabbits. The TEC grafts demonstrated remarkable mechanical strength and maintained a stable cartilaginous phenotype both in vitro and at 6 months post-implantation in immunodeficient mice. When employed as autografts to reconstruct tarsal plate defects in rabbits' upper eyelids, these TEC grafts successfully restored normal eyelid morphology, facilitated smooth eyelid movement, and preserved the histological structure of the conjunctival epithelium. When applied in bilayered tarsoconjunctival defect reconstruction, these TEC grafts not only maintained the normal contour of the upper eyelid but also supported conjunctival epithelial cell migration and growth from the defect margin towards the centre. These findings highlight that auricular chondrocyte-based TEC grafts hold great promise as potential candidates for clinical posterior lamellar reconstruction. STATEMENT OF SIGNIFICANCE: The complex structure and function of the posterior lamellar eyelid continue to be significant challenges for clinical reconstructive surgeries. In this study, we utilized autologous auricular chondrocyte-based TEC grafts for posterior lamellar eyelid reconstruction in a preclinical rabbit model. The TEC grafts exhibited native cartilaginous histomorphology and comparable mechanical strength to those of the native human tarsal plate. In rabbit models with either tarsal plate defects alone or bilayered tarsoconjunctival defects, TEC grafts successfully restored the normal eyelid contour and movement, as well as supported preservation and growth of conjunctival epithelium. This is the first study to demonstrate autologous TEC grafts can be employed for repairing tarsal plate defects, thereby offering an alternative therapeutic approach for treating posterior lamellar defects in clinic settings.

Surgical Correction of Cicatricial Lower Eyelid Retraction: A Systematic Review

BACKGROUND

Cicatricial lower eyelid retraction is a challenging condition. It involves scarring of the lower eyelid, which causes it to retract and expose the sclera. This can lead to complications such as dry eye syndrome and corneal melting. It can be caused by trauma, burns, or previous eyelid surgery. Detailed assessment and understanding of eyelid anatomy and retraction are critical for successful surgical planning. Dynamic and static examinations of the eyelid including measurements of the lower eyelid margin reflex distance (MRD2) and scleral show are also essential to determine the appropriate treatment approach.

METHODS

A systematic review was conducted using Medline, Scopus, and Cochrane databases with keywords related to cicatricial lower eyelid retraction. The publication language was limited to English after 2000. A total of 29 articles were included for data extraction and analysis.

RESULTS

The main surgical techniques include tarsoconjunctival grafts, spacers, midface lift, and lateral canthal tendon suspension, although no single procedure has been universally recognized as the gold standard. New innovations such as synthetic grafts and xenografts are being explored for their potential in eyelid reconstruction. Severe cases, defined as those with inferior scleral show greater than 2 mm, may require a combination of reconstruction methods.

CONCLUSIONS

Correcting cicatricial lower eyelid retraction is a major challenge in oculoplastic reconstruction. The surgical approach should be individualized, considering the pathologies and etiologies of lid retraction. In-depth knowledge and careful surgical planning are essential for best outcomes. There is no gold standard technique, and postoperative outcomes, complications, and management vary depending on the surgical approach used.

Auricular Cartilage Graft for Lengthening Levator Muscle Aponeurosis With Ectropion Correction for Paralytic Lagophthalmos

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

What Is the Best Candidate to Replace the Tarsus? A Biomechanical, Histological, and Optical Study Comparing Five Grafts

Purpose

Reconstruction of the posterior lamella after eyelid tumor removal is challenging and not consensual. Tarsus is the most suitable graft, but is only available in small amounts. Herein, we aim to determine the most appropriate way to replace the tarsus by comparing the biomechanical, histological, and optical properties of five commonly used grafts.

Methods

This study was conducted at the University hospital of Nice between June 2019 and June 2020. Five posterior lamella grafts (tarsus, conchal cartilage, sclera, hard palate, and dermis) were harvested in five fresh frozen cadavers. Biomechanical properties were assessed by tractometry. Collagen and elastin fibers were analyzed by using histological analysis and optical characterization with the second harmonic generation imaging.

Results

The mean Young's modulus was 8.92 MPa (range, 2.90-22.90 MPa), 1.05 MPa (range, 0.39-1.76 MPa), 8.72 MPa (range, 2.0-23.50 MPa), 2.57 MPa (range, 0.41-4.35 MPa), and 1.44 MPa (range, 0.71-2.30 MPa) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. The mean tensile strength was 3 MPa (range, 1.70-6.88 MPa), 0.54 MPa (range, 0.13-0.79 MPa), 2.87 MPa (range, 1.23-5.40 MPa), 1.4 MPa (range, 0.21-2.40 MPa) and 1.0 MPa (range, 0.46-1.43 MPa) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. Hard palate mucosa was the closest to the tarsus regarding the ratio of elastin and collagen fibers. The average second harmonic generation intensity was 221 arbitrary units (a.u.) (range, 165-362 a.u.), 182 a.u. (range, 35-259 a.u.), 369 a.u. (range, 206-533 a.u.), 108 a.u. (range, 34-208 a.u.), and 244 a.u. (range, 195-388 a.u.) for the tarsus, the conchal cartilage, the sclera, the hard palate mucosa, and the dermis, respectively. The hard palate mucosa and the dermis were the closest to the tarsus regarding the collagen fiber size and orientation, respectively.

Conclusions

By attributing 2 points for each characteristic (biomechanical, histological, and optical), the hard palate mucosa and the sclera seem to be the most suitable grafts to replace the tarsus.

Translational Relevance

The aim of this article was to assess the biomechanical, histological and optical characteristics of five of the most commonly used tarsal grafts; this may be helpful in decisions for clinical practice.

Management of eyelid retraction related to thyroid eye disease

Eyelid retraction related to thyroid eye disease (TED) is a challenging condition. It is one of the main clinical signs and a major diagnostic criterion in TED. This condition may threaten vision due to exposure keratopathy, in addition to its esthetic alterations, which may lead to psychosocial implications and affect the patient's quality of life. Although it is more commonly observed in the upper eyelid, it may be present on both the upper and lower lids. Numerous surgical and nonsurgical treatment modalities have been described and will be reviewed in this article. Management should be based on an individual patient assessment, taking into consideration the disease stage, severity, and clinician experience.

Selection of Site for Harvesting Dermal Grafts as a Spacer in the Correction of Eyelid Retraction

BACKGROUND

Several materials can serve as spacer grafts in the repair of retracted lower eyelids. However, previous studies did not reveal any of these to be superior to the others. From our perspective, autologous dermal grafts are ideal because they are biologically compatible and abundantly available. However, the absorption of these grafts is an issue, and the thickness of the dermal grafts is crucial. We evaluated the dermal thickness at five potential donor sites using ultrasonography and the efficacy and safety of the posterior neck dermis as a spacer graft in the correction of retracted lower eyelids.

METHODS

In 20 healthy volunteers, the dermal thickness was assessed using ultrasonography and compared between the posterior neck, upper arm, inguinal area, intergluteal cleft, and gluteal sulcus. Between January 2018 and June 2021, eight retracted lower eyelids in eight patients were repaired using a posterior neck dermal graft. The surgical results of these grafts were also evaluated.

RESULTS

The mean age of the volunteers was 37.8 years, and the mean body mass index was 24.45 kg/m². The intergluteal cleft provided the thickest dermis followed by the posterior neck and gluteal sulcus, which were not significantly different. The upper arm and inguinal area had the thinnest dermis without significant differences between them. The mean marginal reflex distance 2/iris ratio decreased by 0.15 (p=0.008). The mean cosmetic score (0-10) for evaluation of lower eyelid reconstruction increased by 3.38 (p=0.011). The mean Vancouver Scar Scale score for evaluation of donor site scarring was 3.21.

CONCLUSIONS

Although the posterior neck dermis is the second thickest, it is an ideal spacer graft in the reconstruction of retracted lower eyelids. Adequate thickness, uncomplicated methods, and a closer surgical field are its advantages. Additionally, donor site morbidity is minimal, with acceptable scarring.

LEVEL OF EVIDENCE IV

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