Reanimation of Paralyzed Eyelids Since 1968 I have been actively involved in the ophthalmologic management of facial paralysis patients on a daily basis. Two general principles have emerged from that experience. First, it is imperative that the ophthalmologist be involved as early as possible in the care of patients with significant lid paralysis. Otherwise, irreversible visual loss may result before appropriate preventive measures have been instituted. Second, the problem the patient has with his eye is typically the major factor, or at least one of the major factors, that prevents him from resuming his normal life activities after the onset of facial paralysis. Our current approach is therefore to evaluate all patients with significant lid paralysis as early as possible in their course, and to undertake to reanimate eyelids in those who require it as soon as that determination can be made. This article represents my own approach to the management of such patients.
EYELID REANIMATION Coals The goals of eyelid reanimation surgery are defined by normal lid function. The primary function of the lids is to protect the cornea. The secondary function of the lids is to participate with other facial muscles in facial expression. The primary function of corneal protection is subserved by lid closure, blinking, and support of the tear lacus. Lid closure and blinking are primarily accomplished by the upper lid. In a patient with a palpebral aperture of 8 to 10 mm, the lower lid usually moves only about 2 mm. Support of the tear
lacus and operation of the lacrimal pump are exclusively lower lid functions. The reservoir of tears needs to be apposed as a meniscus to the eyeball in order for the upper lid edge to be able to pick up the tears and distribute them across the front surface of the cornea in the course of a blink, analogous to a windshield wiper. Tears do not flow down a static drain to leave the eye, but are in fact pumped through the lacrimal system as a result of contraction of the orbicularis musculature of the lower lid. Facial expression is subserved by partial closure of the upper lid and upward movement of the lower lid, as in a broad grin.
Patient Evaluation In evaluating a patient with facial paralysis for possible lid reanimation surgery, a number of questions must be asked: Is the facial paralysis expected to last 6 months or longer? What is the prognosis for spontaneous return of function, aside from how long it takes? Are the deficits in lid function severe enough to require lid surgery, rather than merely medical management? Are there associated neurologic deficits, such as corneal anesthesia secondary to fifth nerve involvement, or other specific medical or social indications for undertaking surgery? Specific surgical indications have been reviewed previously.1 If the patient meets the criteria for surgery, what are the possibilities? Clearly, it would be advantageous to undertake a procedure that could restore all of the normal lid functions. The only way to accomplish this is to reinnervate the lids. For example, if a patient had a facial nerve neuroma and the
Clinical Professor, University of Southern California, Los Angeles, California Reprint requests: Dr. Levine, 3875 Wilshire Blvd., Suite 301, Los Angeles, CA 90010 Copyright ,C1992 by Thieme Medical Publ~shers,Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved
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Robert E . Levine, M.D.
transected ends of the nerve were primarily anastomosed, or joined via a cable graft, such a patient might eventually achieve excellent lid reinnervation. Unfortunately, however, this does not always occur, even if surgery has been performed by very experienced people. The same is true of facial hypoglossal anastomoses, and crossover grafts. When they work well, they provide the best chance for restoring normal lid functions. What options are available if the nerve grafting procedure is unsuccessful, or partially successful? For example, many facial hypoglossal anastomoses that are successful in innervating the lower face and even the lower eyelid well, do little to innervate the upper lid and restore its functions. Also, even successful grafts may require 6 months to a year before the eyelid becomes functional. How is the patient to be managed in the interim? SURGICAL APPROACHES TO THE PARALYZED EYELID It was noted earlier that the primary function of the lids is to protect the cornea. Procedures for doing this can be divided into three categories: static procedures, muscle transplantation or transposition, and implanted prosthetic devices.
the patient with a paralyzed face. In addition, a twopillar tarsorrhaphy restricts vision, since the patient can only see through a small slit, and even a lateral tarsorrhaphy may limit peripheral vision. Tarsorrhaphy also limits the access to the eye for adequate examination. For example, I recently diagnosed glaucoma in a patient whose tarsorrhaphy I had opened prior to undertaking spring implantation. In the presence of the tarsorrhaphy, adequate tonometry had not been previously performed by her physicians, not could it be adequately performed when I initially saw her. In addition, tarsorrhaphy may not accomplish the primary goal of protecting the cornea. Fibrosis and stretching of tarsorrhaphies can fix the lid in permanently open positions, so that a portion of the cornea is constantly exposed. In some instances, that exposure, and its consequences, may be greater than if no surgery had been performed. In cases of transient paralysis, when the tarsorrhaphy is taken down, residua often include a deformed lid margin and trichiasis, that is, lashes which grow abnormally and rub against the globe. For all of the foregoing reasons, I rarely encounter a patient in whom I feel tarsorrhaphy to be the procedure of choice. Its major application is in patients with severe neurotrophic keratitis secondary to fifth nerve involvement who can be managed in no way other than nearly completely closing the lids.
Static Procedures Although static procedures are not animation procedures, they must be considered in any discussion of eyelid reanimation for two reasons. First, because the vast majority of facial paralysis patients are, in fact, treated with static procedures rather than reanimation. Second, selected static procedures can effectively complement reanimation procedures. Tarsorrhaphy Tarsorrhaphy is undoubtedly the most common procedure utilized to protect the cornea in the presence of paralyzed lids. The simplicity with which it can be performed and undone and the minimal amount of training required for its performance are its major advantages. In patient's with mild paralysis, patients with good corneal sensation and normal Bell's phenomenon and tear function, lateral tarsorrhaphy may be all that is required to protect the cornea. In more severe cases, a two-pillar tarsorrhaphy, leaving the patient with a small slit through which to see, may also successfully protect the cornea. The main disadvantage of tarsorrhaphy is that the procedure adds an additional cosmetic and psychologic burden to the already difficult rehabilitation of
Canthoplasty Medial and lateral canthoplasty are procedures for tightening the lower lid and apposing it to the globe by shortening or redirecting the pull of the canthal tendons. Although canthoplasty requires a more detailed knowledge of lid anatomy than does tarsorrhaphy, it has the advantage of leaving the lid margin and lashes intact, should the canthoplasty need to be undone in the future. Canthoplasty is also not likely to fixate the eyelids in an open position, as may tarsorrhaphy. Canthoplasty is a valuable adjunct in dealing with the lower lid position when reanimation surgery is undertaken in the upper lid. In cases of mild paralysis, where the lower lid droop contributes significantly to the deranged ocular physiology, canthoplasty alone may provide an adequate safety margin so that no additional surgery will be required.
Muscle Transposition or Transplantation An excellent review of this subject has been done by Baker.2 The basic principle is to develop a slip of either temporalis or masseter muscle, and to thread
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
REANIMATING PARALYZED EYELIDS-Levine
Implant of Prosthetic Devices
Gold Weights By placing a weight in the upper lid, gravity assists lid closure. In mild cases of facial paralysis, the extra help the weight provides may be all that is required. In severe cases, the bulk of the large weight that would be required becomes a major limitation to its use. Also, adequate lid closure may not be accomplished in the supine position. Ease of placing a gold weight and its ease of removal are factors in its favor. Lid Magnets Magnets may be placed in the upper and lower lids which will hold the lid shut during sleep. Unfortunately, however, magnets do not contribute to lid closure during the waking hours. Silastic Elastic Prosthesis This prosthesis consists of a silastic band, 1.0 mm in diameter, that is sewn through the medial canthal tendon, passed through the upper and lower lids between tarsus and obicularis, and anchored to the lateral orbital rim. Although anchoring the prosthesis to the rim by drilling through bone is the technique originally described, I have found it quite adequate to secure the prosthesis with sutures to lateral orbital rim periosteum. This procedure has the advantages of suspending the lower lid in a position where it is well apposed to the globe and also provides supplementary closure to the upper lid. The ability of the prosthesis to close the eye weakens with time, over a period ranging from 3 to 12 months. The fact that it functionally self destructs may work out very well in a patient who is recovering obicularis function at a rate similar to which the prosthesis is losing strength. Based on my experience with over a 100 Silastic elastic prosthesis implantations, I would not recommend the procedure for a patient who is still expected to need significant assistance in lid closure beyond 1 year. The procedure should also not be used in patients who
require excellent lid closure on an ongoing basis even during the first year, for example, patients with associated corneal anesthesia or absent Bell's phenomenon. On the other hand, the procedure is excellent for those patients with a marked lower lid component to their problem who do not require much help in upper lid closure. It can provide an excellent cosmetic and functional result in the properly selected patient. Palpebral Spring Based on my experience with implanting the palpebral spring in nearly 600 patients since 1968, I believe this procedure to be the single best modality for reanimating the paralyzed upper eyelid. It consists of a spring made of stainless steel orthodontic wire with a configuration analogous to a safety pin. The upper arm of the spring is sutured to lateral orbital rim periosteum and is fixed, whereas the lower arm of the spring is situated between orbicularis and tarsus of the upper lid and is mobile. Like the Silastic elastic prosthesis, the spring opposes the levator muscle. When the levator is innervated, it overcomes the spring and pulls the lid open. When there is no innervation to the levator, the spring takes over and pushes the lid shut. Unlike the Silastic elastic prosthesis, the spring wire does not generally weaken with time. Unlike muscle transposition procedures, the blink achieved with a spring is physiologic and does not require concerted effort by the patient. The spring may be left in place for months to years. If some orbicularis function returns, resulting in excess lid closure, the spring may be loosened by making a small opening in the lid under local anesthetic and bending the wire. If functional return is complete and the spring is no longer needed, it may be removed without any significant functional or cosmetic residual. Since there is still some closing tension even in the open position, slight pseudoptosis is present because of the spring. If tight closure is not mandatory in a given patient, the pseudoptosis can be decreased by loosening the spring. The same closing tension is also present in successful Silastic prosthesis implantations and gold weight implantations, and slight pseudoptosis also results with these techniques. The principal concern for the use of a palpebral spring, especially for the long-term, is extrusion or dislocation of the lower arm. It should therefore be done only in patients who have access to adequate medical follow-up. With the current technique of suturing the arm within a Dacron envelope, which granulates to the tarsus, that problem has been reduced to a minimum. In addition, a fibrous sleeve envelopes the entire spring and Dacron complex, so
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it through the eyelids and anchor it medially. The tonus of the muscle is utilized to hold the lower lid against the globe. Closure is accomplished by having the patient simulate biting down. The major advantage of this type of procedure is the use of the patient's own tissue for reconstruction. The results of this type of procedure in the patients I have seen over the years, however, have not been either cosmetically or functionally impressive, even in those patients whose surgeons are well experienced with the technique. In addition, the procedure requires extensive dissection and is not easily reversible. I personally do not perform it.
that after a point, the risk of extrusion may actually decrease rather than increase with time. Because of the constant bending of the wire at the fulcrum, some springs have worn out and broken. If the patient still required assistance with lid closure, the broken springs were replaced with new ones.
SURGICAL TECHNIQUES The Palpebral Spring The palpebral spring was first described by MorelFatio and Lalardrie3 in 1965. Professor Morel-Fatio has subsequently implanted such springs with fairly good results in over 150 patients, and since 1968 I have implanted nearly 600 springs with favorable results. Preoperative Considerations The spring has the same general configuration as an open safety pin. It should be prepared prior to surgery, with adjustments made at the time of surgery. The spring is fashioned by making a loop in a piece of stainless steel orthodontic wire measuring 0.010 inches in diameter. Because the forces involved are so small, fatigability of the wire is not a significant factor. The use of round-nosed pliers to bend the wire and a second pair of pliers to fix the wire is helpful. It is important that the loop at the fulcrum of the spring measures about 5 mm in diameter and is as flat as possible. The fulcrum should be placed as far laterally as possible on the orbital rim. The posterior extension of the loop is the upper arm of the spring, which rests on the periosteum of the orbital rim. The anterior extension of the loop is the lower arm, which will be positioned in the lid overlying the tarsal plate. Two curves are placed in each arm of the spring to make it conform properly to the contour of the lid. One curve is made in the frontal plane to allow the upper arm of the spring to conform to the curvature of the orbital rim and to allow the lower arm to conform to the contour of the upper lid. A second curve is made anteroposteriorly to allow the spring to accommodate the orbital rim above the meridional curvature of the globe below. Operative Procedure The goal of surgery is to place the spring so that the upper arm and fulcrum are fixed to orbital rim periosteum, and the lower arm works against the levator palpebral superioris to push the lid shut (Fig. 1).Then tension is set on the spring so that the levator can work against it to pull the lid open. The patient is positioned on the operating table and a scleral shell is put in place to protect the eye.
Next, 0.5 cc of lidocaine, 2% with epinephrine and hyaluronidase, is injected over the mid-tarsus of the upper lid and an additional 1.0 cc over the lateral orbital rim. Excessive infiltration deforms the lid and resulting akinesia interferes with evaluation of lid function. Separation of the arms of the spring should measure one and a half times the interpalpebral fissure when the lids are open. In cases of severe lagophthalmos, this factor should be increased to two. Because it is subsequently easier to lessen the tension of the spring than to increase it, it is better to have the arms initially too far apart than too close together. A 1 cm incision is made slightly superior to midtarsus at the center of the upper lid, parallel to the lid margin. The dissection is made to expose the anterior surface of the tarsus. Laterally, a 2 cm incision is made overlying the lateral orbital rim. The dissection is carried down to the periosteum. Hemostasis is achieved at both incisions with bipolar cautery. A blunted 22 gauge spinal needle with its stylet in place is passed from the medial incision, beginning at mid-tarsus, along the plane between the anterior surface of the tarsus and the orbicularis oculi in a slightly inferior direction. The needle is directed to pass about 2 mm superior to the lashes at the lateral extent of the upper lid and to emerge at the lateral incision. The undersurface of the lid should be checked to ensure that the tarsus has not been inadvertently perforated. The end of the previously prepared spring is passed into the needle after the obturator is removed. Then the needle is withdrawn, and the spring is brought into position. A 4-0 Mersilene suture is placed through the fulcrum of the spring to secure it to orbital rim periosteum, taking an extra bite of periosteum in the stitch. The scleral shell is then removed and the spring contours checked with the eye open and closed. The spring should be positioned so that the lower arm moves somewhat posteriorly on opening the lid to accommodate the normal lid movement in that direction. The scleral shell is replaced and two additional 4-0 Mersilene sutures are placed to secure the fulcrum, taking an extra bite of periosteum with each stitch. Loops are then fashioned at the upper and lower ends of the wire with special orthodontic pliers designed for that purpose. The superior loop should be made at the upper end of the lateral incision and the inferior loop at the center of the upper lid, superior to the lower arm of the spring (Fig. 1C). (If the loop is formed inferiorly, the lower arm loses its smooth contour on its palpebral aspect). The wire is then cut and each loop is closed carefully so that there is no sharp free end that may perforate adjacent tissues. It is imperative that the spring be placed precisely so that pressure exerted on adjacent tissues is mini-
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
Figurel. Techniqueof implantation of palpebral spring. A, Lid incision, B, Spring, a 0.010 inch round orthodontic wire, is threaded through a 22-gauge spinal needle and brought into position as needle is withdrawn. C, Spring is adjusted to conform to lid contours and secured at its fulcrum to periosteum. Lower end of spring is encased in pressed Dacron patch material. A suture of 8-0 nylon (insert) is passed through both surfaces of the Dacron and through the wire loop to prevent slippage. D, Cross-sectional view to show upper arm of spring secured to periosteum and lower arm secured between tarsus and orbicularis muscle. (Reprinted with permission from House WF, et al4.)
mal. Any point of pressure on the tissues could potentially lead to migration or extrusion of the spring. Therefore the lower loop should be flat against the tarsus and parallel to it; similarly the upper loop should be flat against the periosteum. The lower loop position should be checked with the eyes open and closed, with the scleral shell removed. Opening the eyelids causes the upper lid to move posteriorly as well as superiorly. The lower loop of the spring must therefore be oriented slightly posteriorly so as to remain nearly parallel to the tarsus when the lid is opened as well as when it is closed. The lower loop of the spring is not sutured. Rather, it is secured in position by encasing it in a folded piece of 0.2 mm thick Dacron patch material. The crease in the Dacron is best obtained by folding the material in a Gelfoam press that is subsequently put
through a normal steam autoclave cycle. A piece of the folded Dacron approximately 5 mm wide and 10 mm long is cut and placed around the wire, with the crease directed toward the lid margin. A suture of 8-0 nylon is passed through both surfaces of the Dacron as well as through the wire loop to prevent the wire from slipping out of the Dacron envelope. The Dacron is held in position in the upper lid by closing overlying tissues meticulously with vertical mattress sutures and interrupted skin sutures of 6-0 Polydek. Final tension can then be placed on the spring either by varying the position of the upper arm or by bending the wire with two instruments. The upper arm is secured to periosteum with three 4-0 Mersilene sutures, taking an extra bite of periosteum with each stitch. A final inspection of the spring is
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REANIMATING PARALYZED EYELIDS-Levine
made with the patient seated and supine and the tension adjusted if necessary. Slight over-correction is desirable. The deep aspect of the lateral wound is closed with 5-0 plain sutures; interrupted or running 6-0 Polydek sutures are used for skin. The eye is dressed with antimicrobial ointment and a moderate pressure dressing, which is removed the next day. Moderate lid swelling resolves over the following week, and skin sutures are then removed. Spring adjustments can be made easily in the office if necessary, for example to compensate for partial return of seventh nerve function. After injection of a small amount of local anesthetic, an incision is made just above the lower arm of the spring adjacent to the fulcrum and 0.5 cm of wire is exposed. Tension on the wire is adjusted with two pairs of pliers, and the wound is closed with one or two sutures. Refinements in Technique In the earliest spring implants, the loop in the lower arm of the spring was sutured to the orbicularis with 4-0 Mersilene sutures. These elicited too much foreign body reaction, so 7-0 silk sutures were used. Care had to be taken to get an adequate bite of tarsus without at the same time putting the suture so deep that it punctured the inner conjuntiva. Morel-Fatio suggested using Dacron felt to envelop the lower loop, and allowing it to fibrose to tarsus without sutures. This technique worked quite well, except that fine strands of felt tended to perforate the overlying - tissues. For this reason, Dacron velour, which is smooth on the outside, was tried and found to be more suitable except for a bump resulting from the thickness of the velour. Dacron patch material which is only 0.2 mm thick and, like velour, has no fibers on the outside surface, was then tried. This material elicits enough granulomatous reaction to fix it firmly to surrounding tissues, but because the amount of granulation tissue forming between the inside surfaces of the envelope is apparently less than with velour, the spring tended to slip out of its envelope. Placing a single 8-0 nylon suture through the envelope and spring loop to prevent slippage has alleviated this problem. Since there is tension on the spring with the lid open, the palpebral aperture on the involved side is liable to be narrower than that on the uninvolved side. If the spring tension is decreased to allow for wider opening in the primary position, residual lagophthalmos may result on attempted lid closure. Three technique modifications are helpful in ameliorating this problem. First, whereas formerly the fulcrum of the spring was anchored right at the orbital rim, it is now anchored as far lateral as possible before falling into the temporal fossa. This positioning has improved the amount of opening pos-
sible while still retaining full closing tension. Second, the spring tension in the open position has been reduced by the use of thinner wire: 0.010 inch wire is used routinely in place of the 0.011 inch wire used previously. Third, complete closure is no longer the goal in all cases. Patients with poor or absent Bell's phenomenon or associated corneal anesthesia require full lid closure. However, many patients with good Bell's phenomenon and normally innervated corneas can tolerate several millimeters of residual lagophthalmos without any difficulty. The spring tension is therefore set as a compromise between adequate closure and adequate opening. Despite all of the limitations discussed, implantation of a palpebral spring, frequently combined with a medial canthoplasty, is the procedure of choice in patients with severe lagophthalmos and/or other factors predisposing to corneal problems, such as poor Bell's phenomenon or corneal anesthesia. A tarsorrhaphy may or may not adequately protect the cornea. Even when it does protect the cornea, it limits peripheral vision, and imposes an additional cosmetic and psychologic burden on the patient with a paralyzed face. Unlike the Silastic prosthesis, the spring does not weaken with time, provides dependable lid closure, and can easily be adjusted in the office.
SUMMARY AND CONCLUSIONS
>
Patients requiring lid animation should be identified and treated at the earliest possible time after the onset of facial paralysis so that the eye problem does not limit the patient's rehabilitation potential. The best way to animate the lids is to establish reinnervation. If that is not possible, the procedure that I favor in patients with significant orbicularis weakness is spring implantation in the upper lid and canthoplasty to reposition the lower lid against the globe. In milder cases, canthoplasty, gold weight implantation, or Silastic elastic prosthesis implantation may be the procedure of choice.
REFERENCES 1. May M (ed): The Facial Nerve. New York: Thieme-Stratton, 1986 2. Baker DC: Ophthalmic plastic and reconstructive surgery In Smith BC, et al (eds): , vol 1. St. Louis: CV Mosby, 1987, pp 580-590 3. Morel-Fatio D, Lalardrie JP: Le ressort palpabral: Contribution a I'etude de chirurgie plastique de la paralysie faciale. Neurochir 11:303, 1965 4. House WE Luetje CM (eds): Acoustic Tumors, Vol2. Baltimore: University Park Press, 1979
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
EYELID REANIMATION Coals The goals of eyelid reanimation surgery are defined by normal lid function. The primary function of the lids is to protect the cornea. The secondary function of the lids is to participate with other facial muscles in facial expression. The primary function of corneal protection is subserved by lid closure, blinking, and support of the tear lacus. Lid closure and blinking are primarily accomplished by the upper lid. In a patient with a palpebral aperture of 8 to 10 mm, the lower lid usually moves only about 2 mm. Support of the tear
lacus and operation of the lacrimal pump are exclusively lower lid functions. The reservoir of tears needs to be apposed as a meniscus to the eyeball in order for the upper lid edge to be able to pick up the tears and distribute them across the front surface of the cornea in the course of a blink, analogous to a windshield wiper. Tears do not flow down a static drain to leave the eye, but are in fact pumped through the lacrimal system as a result of contraction of the orbicularis musculature of the lower lid. Facial expression is subserved by partial closure of the upper lid and upward movement of the lower lid, as in a broad grin.
Patient Evaluation In evaluating a patient with facial paralysis for possible lid reanimation surgery, a number of questions must be asked: Is the facial paralysis expected to last 6 months or longer? What is the prognosis for spontaneous return of function, aside from how long it takes? Are the deficits in lid function severe enough to require lid surgery, rather than merely medical management? Are there associated neurologic deficits, such as corneal anesthesia secondary to fifth nerve involvement, or other specific medical or social indications for undertaking surgery? Specific surgical indications have been reviewed previously.1 If the patient meets the criteria for surgery, what are the possibilities? Clearly, it would be advantageous to undertake a procedure that could restore all of the normal lid functions. The only way to accomplish this is to reinnervate the lids. For example, if a patient had a facial nerve neuroma and the
Clinical Professor, University of Southern California, Los Angeles, California Reprint requests: Dr. Levine, 3875 Wilshire Blvd., Suite 301, Los Angeles, CA 90010 Copyright ,C1992 by Thieme Medical Publ~shers,Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved
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Robert E . Levine, M.D.
transected ends of the nerve were primarily anastomosed, or joined via a cable graft, such a patient might eventually achieve excellent lid reinnervation. Unfortunately, however, this does not always occur, even if surgery has been performed by very experienced people. The same is true of facial hypoglossal anastomoses, and crossover grafts. When they work well, they provide the best chance for restoring normal lid functions. What options are available if the nerve grafting procedure is unsuccessful, or partially successful? For example, many facial hypoglossal anastomoses that are successful in innervating the lower face and even the lower eyelid well, do little to innervate the upper lid and restore its functions. Also, even successful grafts may require 6 months to a year before the eyelid becomes functional. How is the patient to be managed in the interim? SURGICAL APPROACHES TO THE PARALYZED EYELID It was noted earlier that the primary function of the lids is to protect the cornea. Procedures for doing this can be divided into three categories: static procedures, muscle transplantation or transposition, and implanted prosthetic devices.
the patient with a paralyzed face. In addition, a twopillar tarsorrhaphy restricts vision, since the patient can only see through a small slit, and even a lateral tarsorrhaphy may limit peripheral vision. Tarsorrhaphy also limits the access to the eye for adequate examination. For example, I recently diagnosed glaucoma in a patient whose tarsorrhaphy I had opened prior to undertaking spring implantation. In the presence of the tarsorrhaphy, adequate tonometry had not been previously performed by her physicians, not could it be adequately performed when I initially saw her. In addition, tarsorrhaphy may not accomplish the primary goal of protecting the cornea. Fibrosis and stretching of tarsorrhaphies can fix the lid in permanently open positions, so that a portion of the cornea is constantly exposed. In some instances, that exposure, and its consequences, may be greater than if no surgery had been performed. In cases of transient paralysis, when the tarsorrhaphy is taken down, residua often include a deformed lid margin and trichiasis, that is, lashes which grow abnormally and rub against the globe. For all of the foregoing reasons, I rarely encounter a patient in whom I feel tarsorrhaphy to be the procedure of choice. Its major application is in patients with severe neurotrophic keratitis secondary to fifth nerve involvement who can be managed in no way other than nearly completely closing the lids.
Static Procedures Although static procedures are not animation procedures, they must be considered in any discussion of eyelid reanimation for two reasons. First, because the vast majority of facial paralysis patients are, in fact, treated with static procedures rather than reanimation. Second, selected static procedures can effectively complement reanimation procedures. Tarsorrhaphy Tarsorrhaphy is undoubtedly the most common procedure utilized to protect the cornea in the presence of paralyzed lids. The simplicity with which it can be performed and undone and the minimal amount of training required for its performance are its major advantages. In patient's with mild paralysis, patients with good corneal sensation and normal Bell's phenomenon and tear function, lateral tarsorrhaphy may be all that is required to protect the cornea. In more severe cases, a two-pillar tarsorrhaphy, leaving the patient with a small slit through which to see, may also successfully protect the cornea. The main disadvantage of tarsorrhaphy is that the procedure adds an additional cosmetic and psychologic burden to the already difficult rehabilitation of
Canthoplasty Medial and lateral canthoplasty are procedures for tightening the lower lid and apposing it to the globe by shortening or redirecting the pull of the canthal tendons. Although canthoplasty requires a more detailed knowledge of lid anatomy than does tarsorrhaphy, it has the advantage of leaving the lid margin and lashes intact, should the canthoplasty need to be undone in the future. Canthoplasty is also not likely to fixate the eyelids in an open position, as may tarsorrhaphy. Canthoplasty is a valuable adjunct in dealing with the lower lid position when reanimation surgery is undertaken in the upper lid. In cases of mild paralysis, where the lower lid droop contributes significantly to the deranged ocular physiology, canthoplasty alone may provide an adequate safety margin so that no additional surgery will be required.
Muscle Transposition or Transplantation An excellent review of this subject has been done by Baker.2 The basic principle is to develop a slip of either temporalis or masseter muscle, and to thread
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
REANIMATING PARALYZED EYELIDS-Levine
Implant of Prosthetic Devices
Gold Weights By placing a weight in the upper lid, gravity assists lid closure. In mild cases of facial paralysis, the extra help the weight provides may be all that is required. In severe cases, the bulk of the large weight that would be required becomes a major limitation to its use. Also, adequate lid closure may not be accomplished in the supine position. Ease of placing a gold weight and its ease of removal are factors in its favor. Lid Magnets Magnets may be placed in the upper and lower lids which will hold the lid shut during sleep. Unfortunately, however, magnets do not contribute to lid closure during the waking hours. Silastic Elastic Prosthesis This prosthesis consists of a silastic band, 1.0 mm in diameter, that is sewn through the medial canthal tendon, passed through the upper and lower lids between tarsus and obicularis, and anchored to the lateral orbital rim. Although anchoring the prosthesis to the rim by drilling through bone is the technique originally described, I have found it quite adequate to secure the prosthesis with sutures to lateral orbital rim periosteum. This procedure has the advantages of suspending the lower lid in a position where it is well apposed to the globe and also provides supplementary closure to the upper lid. The ability of the prosthesis to close the eye weakens with time, over a period ranging from 3 to 12 months. The fact that it functionally self destructs may work out very well in a patient who is recovering obicularis function at a rate similar to which the prosthesis is losing strength. Based on my experience with over a 100 Silastic elastic prosthesis implantations, I would not recommend the procedure for a patient who is still expected to need significant assistance in lid closure beyond 1 year. The procedure should also not be used in patients who
require excellent lid closure on an ongoing basis even during the first year, for example, patients with associated corneal anesthesia or absent Bell's phenomenon. On the other hand, the procedure is excellent for those patients with a marked lower lid component to their problem who do not require much help in upper lid closure. It can provide an excellent cosmetic and functional result in the properly selected patient. Palpebral Spring Based on my experience with implanting the palpebral spring in nearly 600 patients since 1968, I believe this procedure to be the single best modality for reanimating the paralyzed upper eyelid. It consists of a spring made of stainless steel orthodontic wire with a configuration analogous to a safety pin. The upper arm of the spring is sutured to lateral orbital rim periosteum and is fixed, whereas the lower arm of the spring is situated between orbicularis and tarsus of the upper lid and is mobile. Like the Silastic elastic prosthesis, the spring opposes the levator muscle. When the levator is innervated, it overcomes the spring and pulls the lid open. When there is no innervation to the levator, the spring takes over and pushes the lid shut. Unlike the Silastic elastic prosthesis, the spring wire does not generally weaken with time. Unlike muscle transposition procedures, the blink achieved with a spring is physiologic and does not require concerted effort by the patient. The spring may be left in place for months to years. If some orbicularis function returns, resulting in excess lid closure, the spring may be loosened by making a small opening in the lid under local anesthetic and bending the wire. If functional return is complete and the spring is no longer needed, it may be removed without any significant functional or cosmetic residual. Since there is still some closing tension even in the open position, slight pseudoptosis is present because of the spring. If tight closure is not mandatory in a given patient, the pseudoptosis can be decreased by loosening the spring. The same closing tension is also present in successful Silastic prosthesis implantations and gold weight implantations, and slight pseudoptosis also results with these techniques. The principal concern for the use of a palpebral spring, especially for the long-term, is extrusion or dislocation of the lower arm. It should therefore be done only in patients who have access to adequate medical follow-up. With the current technique of suturing the arm within a Dacron envelope, which granulates to the tarsus, that problem has been reduced to a minimum. In addition, a fibrous sleeve envelopes the entire spring and Dacron complex, so
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it through the eyelids and anchor it medially. The tonus of the muscle is utilized to hold the lower lid against the globe. Closure is accomplished by having the patient simulate biting down. The major advantage of this type of procedure is the use of the patient's own tissue for reconstruction. The results of this type of procedure in the patients I have seen over the years, however, have not been either cosmetically or functionally impressive, even in those patients whose surgeons are well experienced with the technique. In addition, the procedure requires extensive dissection and is not easily reversible. I personally do not perform it.
that after a point, the risk of extrusion may actually decrease rather than increase with time. Because of the constant bending of the wire at the fulcrum, some springs have worn out and broken. If the patient still required assistance with lid closure, the broken springs were replaced with new ones.
SURGICAL TECHNIQUES The Palpebral Spring The palpebral spring was first described by MorelFatio and Lalardrie3 in 1965. Professor Morel-Fatio has subsequently implanted such springs with fairly good results in over 150 patients, and since 1968 I have implanted nearly 600 springs with favorable results. Preoperative Considerations The spring has the same general configuration as an open safety pin. It should be prepared prior to surgery, with adjustments made at the time of surgery. The spring is fashioned by making a loop in a piece of stainless steel orthodontic wire measuring 0.010 inches in diameter. Because the forces involved are so small, fatigability of the wire is not a significant factor. The use of round-nosed pliers to bend the wire and a second pair of pliers to fix the wire is helpful. It is important that the loop at the fulcrum of the spring measures about 5 mm in diameter and is as flat as possible. The fulcrum should be placed as far laterally as possible on the orbital rim. The posterior extension of the loop is the upper arm of the spring, which rests on the periosteum of the orbital rim. The anterior extension of the loop is the lower arm, which will be positioned in the lid overlying the tarsal plate. Two curves are placed in each arm of the spring to make it conform properly to the contour of the lid. One curve is made in the frontal plane to allow the upper arm of the spring to conform to the curvature of the orbital rim and to allow the lower arm to conform to the contour of the upper lid. A second curve is made anteroposteriorly to allow the spring to accommodate the orbital rim above the meridional curvature of the globe below. Operative Procedure The goal of surgery is to place the spring so that the upper arm and fulcrum are fixed to orbital rim periosteum, and the lower arm works against the levator palpebral superioris to push the lid shut (Fig. 1).Then tension is set on the spring so that the levator can work against it to pull the lid open. The patient is positioned on the operating table and a scleral shell is put in place to protect the eye.
Next, 0.5 cc of lidocaine, 2% with epinephrine and hyaluronidase, is injected over the mid-tarsus of the upper lid and an additional 1.0 cc over the lateral orbital rim. Excessive infiltration deforms the lid and resulting akinesia interferes with evaluation of lid function. Separation of the arms of the spring should measure one and a half times the interpalpebral fissure when the lids are open. In cases of severe lagophthalmos, this factor should be increased to two. Because it is subsequently easier to lessen the tension of the spring than to increase it, it is better to have the arms initially too far apart than too close together. A 1 cm incision is made slightly superior to midtarsus at the center of the upper lid, parallel to the lid margin. The dissection is made to expose the anterior surface of the tarsus. Laterally, a 2 cm incision is made overlying the lateral orbital rim. The dissection is carried down to the periosteum. Hemostasis is achieved at both incisions with bipolar cautery. A blunted 22 gauge spinal needle with its stylet in place is passed from the medial incision, beginning at mid-tarsus, along the plane between the anterior surface of the tarsus and the orbicularis oculi in a slightly inferior direction. The needle is directed to pass about 2 mm superior to the lashes at the lateral extent of the upper lid and to emerge at the lateral incision. The undersurface of the lid should be checked to ensure that the tarsus has not been inadvertently perforated. The end of the previously prepared spring is passed into the needle after the obturator is removed. Then the needle is withdrawn, and the spring is brought into position. A 4-0 Mersilene suture is placed through the fulcrum of the spring to secure it to orbital rim periosteum, taking an extra bite of periosteum in the stitch. The scleral shell is then removed and the spring contours checked with the eye open and closed. The spring should be positioned so that the lower arm moves somewhat posteriorly on opening the lid to accommodate the normal lid movement in that direction. The scleral shell is replaced and two additional 4-0 Mersilene sutures are placed to secure the fulcrum, taking an extra bite of periosteum with each stitch. Loops are then fashioned at the upper and lower ends of the wire with special orthodontic pliers designed for that purpose. The superior loop should be made at the upper end of the lateral incision and the inferior loop at the center of the upper lid, superior to the lower arm of the spring (Fig. 1C). (If the loop is formed inferiorly, the lower arm loses its smooth contour on its palpebral aspect). The wire is then cut and each loop is closed carefully so that there is no sharp free end that may perforate adjacent tissues. It is imperative that the spring be placed precisely so that pressure exerted on adjacent tissues is mini-
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
Figurel. Techniqueof implantation of palpebral spring. A, Lid incision, B, Spring, a 0.010 inch round orthodontic wire, is threaded through a 22-gauge spinal needle and brought into position as needle is withdrawn. C, Spring is adjusted to conform to lid contours and secured at its fulcrum to periosteum. Lower end of spring is encased in pressed Dacron patch material. A suture of 8-0 nylon (insert) is passed through both surfaces of the Dacron and through the wire loop to prevent slippage. D, Cross-sectional view to show upper arm of spring secured to periosteum and lower arm secured between tarsus and orbicularis muscle. (Reprinted with permission from House WF, et al4.)
mal. Any point of pressure on the tissues could potentially lead to migration or extrusion of the spring. Therefore the lower loop should be flat against the tarsus and parallel to it; similarly the upper loop should be flat against the periosteum. The lower loop position should be checked with the eyes open and closed, with the scleral shell removed. Opening the eyelids causes the upper lid to move posteriorly as well as superiorly. The lower loop of the spring must therefore be oriented slightly posteriorly so as to remain nearly parallel to the tarsus when the lid is opened as well as when it is closed. The lower loop of the spring is not sutured. Rather, it is secured in position by encasing it in a folded piece of 0.2 mm thick Dacron patch material. The crease in the Dacron is best obtained by folding the material in a Gelfoam press that is subsequently put
through a normal steam autoclave cycle. A piece of the folded Dacron approximately 5 mm wide and 10 mm long is cut and placed around the wire, with the crease directed toward the lid margin. A suture of 8-0 nylon is passed through both surfaces of the Dacron as well as through the wire loop to prevent the wire from slipping out of the Dacron envelope. The Dacron is held in position in the upper lid by closing overlying tissues meticulously with vertical mattress sutures and interrupted skin sutures of 6-0 Polydek. Final tension can then be placed on the spring either by varying the position of the upper arm or by bending the wire with two instruments. The upper arm is secured to periosteum with three 4-0 Mersilene sutures, taking an extra bite of periosteum with each stitch. A final inspection of the spring is
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REANIMATING PARALYZED EYELIDS-Levine
made with the patient seated and supine and the tension adjusted if necessary. Slight over-correction is desirable. The deep aspect of the lateral wound is closed with 5-0 plain sutures; interrupted or running 6-0 Polydek sutures are used for skin. The eye is dressed with antimicrobial ointment and a moderate pressure dressing, which is removed the next day. Moderate lid swelling resolves over the following week, and skin sutures are then removed. Spring adjustments can be made easily in the office if necessary, for example to compensate for partial return of seventh nerve function. After injection of a small amount of local anesthetic, an incision is made just above the lower arm of the spring adjacent to the fulcrum and 0.5 cm of wire is exposed. Tension on the wire is adjusted with two pairs of pliers, and the wound is closed with one or two sutures. Refinements in Technique In the earliest spring implants, the loop in the lower arm of the spring was sutured to the orbicularis with 4-0 Mersilene sutures. These elicited too much foreign body reaction, so 7-0 silk sutures were used. Care had to be taken to get an adequate bite of tarsus without at the same time putting the suture so deep that it punctured the inner conjuntiva. Morel-Fatio suggested using Dacron felt to envelop the lower loop, and allowing it to fibrose to tarsus without sutures. This technique worked quite well, except that fine strands of felt tended to perforate the overlying - tissues. For this reason, Dacron velour, which is smooth on the outside, was tried and found to be more suitable except for a bump resulting from the thickness of the velour. Dacron patch material which is only 0.2 mm thick and, like velour, has no fibers on the outside surface, was then tried. This material elicits enough granulomatous reaction to fix it firmly to surrounding tissues, but because the amount of granulation tissue forming between the inside surfaces of the envelope is apparently less than with velour, the spring tended to slip out of its envelope. Placing a single 8-0 nylon suture through the envelope and spring loop to prevent slippage has alleviated this problem. Since there is tension on the spring with the lid open, the palpebral aperture on the involved side is liable to be narrower than that on the uninvolved side. If the spring tension is decreased to allow for wider opening in the primary position, residual lagophthalmos may result on attempted lid closure. Three technique modifications are helpful in ameliorating this problem. First, whereas formerly the fulcrum of the spring was anchored right at the orbital rim, it is now anchored as far lateral as possible before falling into the temporal fossa. This positioning has improved the amount of opening pos-
sible while still retaining full closing tension. Second, the spring tension in the open position has been reduced by the use of thinner wire: 0.010 inch wire is used routinely in place of the 0.011 inch wire used previously. Third, complete closure is no longer the goal in all cases. Patients with poor or absent Bell's phenomenon or associated corneal anesthesia require full lid closure. However, many patients with good Bell's phenomenon and normally innervated corneas can tolerate several millimeters of residual lagophthalmos without any difficulty. The spring tension is therefore set as a compromise between adequate closure and adequate opening. Despite all of the limitations discussed, implantation of a palpebral spring, frequently combined with a medial canthoplasty, is the procedure of choice in patients with severe lagophthalmos and/or other factors predisposing to corneal problems, such as poor Bell's phenomenon or corneal anesthesia. A tarsorrhaphy may or may not adequately protect the cornea. Even when it does protect the cornea, it limits peripheral vision, and imposes an additional cosmetic and psychologic burden on the patient with a paralyzed face. Unlike the Silastic prosthesis, the spring does not weaken with time, provides dependable lid closure, and can easily be adjusted in the office.
SUMMARY AND CONCLUSIONS
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Patients requiring lid animation should be identified and treated at the earliest possible time after the onset of facial paralysis so that the eye problem does not limit the patient's rehabilitation potential. The best way to animate the lids is to establish reinnervation. If that is not possible, the procedure that I favor in patients with significant orbicularis weakness is spring implantation in the upper lid and canthoplasty to reposition the lower lid against the globe. In milder cases, canthoplasty, gold weight implantation, or Silastic elastic prosthesis implantation may be the procedure of choice.
REFERENCES 1. May M (ed): The Facial Nerve. New York: Thieme-Stratton, 1986 2. Baker DC: Ophthalmic plastic and reconstructive surgery In Smith BC, et al (eds): , vol 1. St. Louis: CV Mosby, 1987, pp 580-590 3. Morel-Fatio D, Lalardrie JP: Le ressort palpabral: Contribution a I'etude de chirurgie plastique de la paralysie faciale. Neurochir 11:303, 1965 4. House WE Luetje CM (eds): Acoustic Tumors, Vol2. Baltimore: University Park Press, 1979
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FACIAL PLASTIC SURGERY Volume 8, Number 2 April 1992
