Periorbital Reconstruction in Facial Paralysis

The primary function of the eyelids is to maintain ocular health and protection. In facial paralysis, neurogenic dysfunction orbicularis oculi muscle complex leads a spectrum periocular issues including xerophthalmia, exposure keratopathy, lower eyelid malposition contributing epiphora deformity. Conservative techniques can foster safe environment for patients awaiting surgical intervention. Eyelid coupling using combined tightening modified tarsoconjunctival flap our preferred technique older with flaccid usually performed platinum weight. Medial ectropion remains difficult area those senile changes. For best outcomes, midface must be lifted reanimation, sling, or temporalis tendon transfer. Herein we describe several chosen improve patients’ cosmetic outcomes after paralysis. Patients present paralysis from variety etiologies such as: acoustic neuroma, temporal bone trauma, idiopathic, iatrogenic, infectious, autoimmune. Those permanent, require management prevent functional aesthetic periorbital impairment. Impaired may lead incomplete eye closure reduced frequency amplitude blink, reducing tear film distribution increasing risk corneal desiccation.1.Bergeron CM Moe KS. evaluation treatment paralysis.Facial Plast Surg. 2008; 24: 231-241Crossref PubMed Scopus (30) Google Scholar,2.Sibony PA Evinger C Manning KA. movements in paralysis.Arch Ophthalmol. 1991; 109: 1555-1561Crossref (46) Scholar Increased surface progressive keratopathy eventual epithelial defects, ulcerations, perforations, scarring, rarely, endophthalmitis loss vision. At baseline, retractors allows pronounced retraction widening vertical palpebral fissure.3.Joseph SS Joseph AW Douglas RS et al.Periocular Reconstruction Facial Paralysis.Otolaryngol Clin North Am. 2016; 49: 475-487Abstract Full Text PDF (11) Diminished tone decreased anti-gravitational pull lid resultant paralytic ectropion.4.Bedran EG Pereira MV TF Bernardes Ectropion.Semin 2010; 25: 59-65Crossref (27) Punctal eversion away globe, addition abnormal active muscular pumping action derangements post-ganglionic parasympathetic activity lacrimal dysfunction, laking, (Figure 1).1.Bergeron Scholar,5.Doane MG. Interactions tears wetting dynamics normal human eyeblink.Am J 1980; 89: 507-516Abstract (303) Even who have nerve return plagued synkinesis, which presents another set dysfunctions. Treatment goals include protection surface, preservation visual function, restoration symmetry. There are temporary long-term options these patients, based on an anticipated recovery (or lack thereof). Comprehensive examination should determination ophthalmologic epithelium, scleral show, presence Bell's phenomenon, MRD1 2 measurements, fissure width, levator laxity, ectropion/entropion, lagophthalmos, brow ptosis. acute setting, aggressive lubrication, humidification form lubricating drops, ointments, moisture chambers, taping, even external weights serve protect quickly effectively exposure. Adjunctive injectable been described (1) chemodenervation palpebrae superioris botulinum toxin induce protective ptosis6.Ellis MF Daniell M. An safety efficacy type A (BOTOX) when used produce ptosis.Clin Exp 2001; 29: 394-399Crossref (62) (2) hyaluronic acid injection augmentation upper loading concurrent expansion reduce retraction.7.Mancini R Khadavi NM Goldberg RA. Nonsurgical margin asymmetry gel filler.Ophthalmic Reconstr 2011; 27: 1-3Crossref (43) Finally, suture tarsorrhaphy utilized physically event that prior conservative measures fail surface.8.Gossman MD Bowe BE Tanenbaum Reversible keratopathy.Ophthalmic 22: 237-239PubMed Long-term typically encompass interventions – selection below. Upper surgically placed assists by countering upward retraction. use implant advantageous its smaller size (due higher density compared gold) capsular inflammation.10.Berghaus Neumann K Schrom T. chain: new upper-lid palsy.Arch 2003; 5: 166-170Crossref (79) Proper weight lightest consistently provides complete volitional blinking; this tested adhesive apply different sized patient's lid. This procedure under local anesthesia other reconstruction procedures. 1.Presurgical marking supraciliary crease (7-10 mm above eyelashes) midpupillary line important accurate placement. Approximately two-thirds three-fourths length planned medial where maximal.2.Local induced subcutaneous 1% lidocaine 1:100,000 epinephrine 30-gauge needle create hydro-dissection hemostasis.3.An incision made through muscle. Blunt elevation provide tarsal plate perichondrium.4.Fine tipped scissor dissection creates precise pocket accommodate shape Traditional placement upon perichondrium 2mm margin. However, more cephalically between aponeurosis orbital septum make less visible but requires heavier weight.5.The then into secured 6-0 polyglactin each hole (at least sutures avoid rotation weight; Figure 2A, B). intermittently everted during communication conjunctiva. layer closed interrupted skin approximated fast absorbing gut polypropylene suture. lateral strip canthoplasty traditional shortening elongated eyelids.11.Anderson RL. strip.Trans New Orleans Acad 1982; 30: 352-363PubMed 1.A canthotomy inferior cantholysis 15 blade, Wescott scissors, and/or monopolar cautery.2.After freeing ligamentous attachments at Whitnall's tubercle, anterior lamellae (skin muscle) excised strip.3.Full thickness excision canthal appropriate needed correct lower-eyelid laxity.4.The remnant conjunctival mucosa denuded blade.5.For suspension strip, 5-0 polydioxanone parachuted horizontal mattress fashion rim (posterior superior tubercle within vault). alternative double armed 4-0 mersilene S2 needle. tagged later cinched down completion (TCF), if concurrently (otherwise it place inset TCF). If TCF not performed, tying creating tension shortening.6.The buried poliglecaprone deep dermal sutures. angle re-created suture, tied beneath silk approximate canthotomy. disruptive albeit powerful retinacular suspension.12.Fagien S. Algorithm canthoplasty: suspension: simplified canthopexy.Plast 1999; 103 (discussion 2054-2048): 2042-2053Crossref (105) suited mild-moderate laxity. 5-7 created 15-blade sparing fissure.2.A freer dissector cotton-tipped applicators palpate near tubercle.3.A perform technique, starting tubercle) subperiosteal plane fashion. TCF, 3).4.The canthopexy adequate shortening.5.The re-approximated gut. Coupling was traditionally completed tarsorrhaphy, edges were very obvious obscured field. (also known as mini-Hughes, transposition) developed appearance combat unopposed effect retraction, improving lagophthalmos.13.Sufyan AS Lee HB Shah H al.Single-stage repair novel modification flap.JAMA 2014; 16: 151-152Crossref (10) Scholar,14.Dedhia RD Shipchandler TZ Tollefson TT. Using Modified Tarsoconjunctival Flap Paralysis.Facial Surg 2021; 447-451Abstract It vector support lax couples dynamic movement lids distribution. often either suspension, above, address laxity coupled loading. 1.This starts above. With fixation until TCF.2.A traction gray over Desmarres retractor. Hydrodissection posterior lamella epinephrine, elevation.3.A superiorly designed along eyelid. design approximately 3 8 wide, depending degree snap test result, ∼4 tall, includes 1 4). cut 15C blade release transposition. 4 height preserved entropion.4.An small sliver sharply receive flap.5.The elevated overlying standard Hughes 5).Figure 5Elevation oculi.View Large Image ViewerDownload Hi-res image Download (PPT)6.This corner well midpoint portion, knots facing sclera irritation.7.The recreated closed. Restoration early success fading results. Our uses transcutaneous approach. 1.The rim/medial region exposed via limited subciliary incision. retrocaruncular approach scar.2.The identified blunt anchoring point crest. To identify crest, fossa colorado bovie incise conjunctiva staying injuring system frequent palpation utilizing ensure trajectory.3.A passed crest periosteum. Stainless steel wires systems durable palpation/extrusion greater 6).15.Kelly CP Cohen AJ Yavuzer al.Medial canthopexy: proven technique.Ophthalmic 2004; 20: 337-341Crossref (25) Scholar,16.Baek S Chung JH Yoon ES al.Algorithm canthopexy.Arch 2018; 45: 525-533Crossref (8) Scholar4.The scar heals concave subunit. When both sling employed comprehensively laxity.17.Tenzel RR Buffam FV Miller GR. "lateral sling" repair.Can 1977; 12: 199-202PubMed fascia lata graft thigh palmaris longus ventral forearm 35 × 10 mm. Incision planning start 6 cm tibial condyle. Orthopedic surgery colleagues assist harvest longus.2.A approach, full tarsus tendons.3.Using thin ribbon autologous graft, medially nasal bones supero-laterally 7A-B).4.Routine followed extended running Paralytic ptosis addressed one techniques. goal symmetry, associated impairment caused achieve norms gender. nonsurgical option treat contralateral frontalis/corrugator muscles symmetry chemodenervation. depends multiple patient factors hairline, forehead rhytids, alopecia. Approaches coronal, trichophytic pretrichial, endoscopic, mid-forehead, direct brow, transblepharoplasty approaches.9.Nahai FR. varied lifting.Clin 2013; 40: 101-104Abstract (12) elderly prominent midforehead lift will effective concealed natural creases. amount estimated measured caliper guides excision.2.A excise mid-forehead skin, centering ellipse limbus. firmer secure fixation, subgaleal window dermis pericranium.3.The scalp undermined nylon diminutive rhytids. 1-2 hairline scalpel beveled hair follicles. similar lift; however, care preserve follicles brow. high bangs benefit pretrichial lift. Endoscopic better younger without undergoing procedures, recommend ophthalmic antibiotic ointment (bacitracin erythromycin) three times daily week. combination steroid topical (such drops containing neomycin, polymyxin B, dexamethasone) week decrease granulation tissue formation. cold compresses first few days head bed edema, bruising chemosis. imperative emphasize thorough education encourage maintenance peri-operatively. potentially devastating complications evaluated treated appropriately. short-term treatment, there many management, majority focus protecting static techniques, tailored unique anatomy, prognosis, goals.