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Gold weight implantation and lateral tarsorrhaphy for upper eyelid paralysis
Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Gold weight implantation and lateral tarsorrhaphy for upper eyelid paralysisq Swee T. Tan a, b, c, *, Jonathan J. Staiano a, Tinte Itinteang a, b, Benjamin C. McIntyre a, Craig A. MacKinnon a, David W. Glasson a a
Head & Neck and Skull Base Surgery/Oncology Programme, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Wellington, New Zealand Gillies McIndoe Research Institute, Wellington, New Zealand c University of Otago, Wellington, New Zealand b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 October 2011 Accepted 16 July 2012
Background: Upper eyelid paralysis leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness. Methods: Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy were identified from our prospective database and reviewed. Results: Sixty-three patients were identified, 36 of whom underwent immediate reanimation procedure either during cancer excision (n ¼ 35) or repair of facial laceration (n ¼ 1). Twenty-seven patients had a delayed procedure either following tumour excision (n ¼ 21) or unresolved Bell’s palsy (n ¼ 3), or facial palsy due to complex craniofacial fracture (n ¼ 3). Nine patients required revision to achieve optimal weight. Fifty-two patients had full eye closure. The remaining 11 patients had almost complete eye closure. Conclusions: Facial paralysis is devastating for the patient and immediate facial reanimation should be performed. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective in achieving eye closure. Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Gold weight Lagophthalmos Facial palsy Reanimation Immediate
1. Introduction Facial palsy is devastating with considerable cosmetic and functional concerns for the affected patients. Paralysis of the orbicularis oculi muscle leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness. Artificial tears, lubricants, eye taping and tarsorrhaphy are useful but they are often inadequate for eye protection. More definitive techniques include the use of magnets (Mühlbauer et al., 1973), palpebral springs (Morel-Fatio and Lalardrie, 1964; May, 1988; McNeil and Oh, 1991; Terzis and Kyere, 2008) and gold weights (Smellie, 1966; Jobe, 1974; May, 1987; Kartush et al., 1990; Terzis and Kyere, 2008). A number of authors have recently published in this Journal advocating immediate facial reanimation by microvascular free flap surgery (Biglioli et al., 2011; Bianchi et al., 2009, 2012). However,
q Parts of this paper were presented at the Australian & New Zealand Head and Neck Cancer Society’s Annual Scientific Meeting, Brisbane, Australia, July 26e28, 2007 and the New Zealand Association of Plastic Surgeons’ Annual Scientific Meeting, Wellington, New Zealand, October 6, 2007. * Corresponding author. Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Private bag 31-907, High Street, Lower Hutt, New Zealand. Tel.: þ64 4 587 2506; fax: þ64 4 587 2510. E-mail address: [email protected] (S.T. Tan).
the majority of our patients are elderly with cancer with limited life expectancy (Ch’ng et al., 2006, 2008). They prefer functional reanimation for immediate improvement in quality of life. Therefore dynamic reanimation procedures using local muscles are commonly used at our Centre, to achieve this aim. Gold weight implantation to the upper eyelid combined with our modified McLaughlin’s lateral tarsorrhaphy (McLaughlin, 1950) is the preferred method for managing lagophthalmos in our Centre. We present our experience with this approach. 2. Material and methods Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy in our Centre between March 2000 and September 2010 were identified from our prospectively maintained head and neck/skull base database and reviewed. 2.1. Management philosophy and approach All head and neck cancer patients were managed through the multi-disciplinary head and neck team setting. Immediate reanimation was performed following the ablative procedure in cases where the facial nerve and/or its branch(es) was paralysed or sacrificed because of tumour involvement. Delayed reconstruction
1010-5182/$ e see front matter Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2012.07.015
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S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
was performed for cases that were referred from other services following ablative surgery. Facial paralysis was categorised as involving the upper, middle and lower thirds of the face. In our Centre, the preferred method of reanimation of the upper third of the face is by gold weight implantation to the upper lid. Except in young patients, a McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification is also performed to optimise eye protection. A browlift is performed for brow ptosis if this is present. A temporalis muscle transfer with fascia lata extension (McLaughlin, 1953) is performed to reanimate the middle third (alar base, upper lip and modiolus), and an anterior belly of digastric muscle transfer for the paralysed lower lip (Tulley et al., 2000; Tan, 2002). In younger patients who undergo sacrifice of the facial nerve trunk, nerve grafting from the proximal facial nerve stump to the frontal and zygomatic branches is performed, in addition to the techniques described above for the upper, middle and lower face. In these patients the gold weight is removed following recovery of the orbicularis oculi muscle function. In young patients in whom the facial nerve is lost at the skull base (e.g., during excision of a large acoustic neuroma), insertion of a gold weight is performed under local anaesthesia upon referral, followed by cross facial nerve grafting. 2.2. Surgical technique
conjunctiva. The orbicularis oculi muscle is approximated with a 6/0 Vicryl and the skin is closed with a subcuticular 6/0 Prolene. Patients with facial paralysis have a wider palpebral aperture, often associated with lower lid laxity, especially in older patients. A McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification is performed to support the lower lid and to narrow the palpebral aperture, which improves the mechanical efficiency of the upper lid closure. This involves excision of a 5 mm narrow triangular strip of the outer margin of the lower eyelid incorporating the eyelashes and adjacent skin near the lateral canthus, down to the tarsal plate. A corresponding narrow triangular strip of the inner lid margin and adjacent conjunctiva from of the upper lid is also excised (Fig. 2A). The lateral extent of the lower lid is then tugged under the upper eyelid, overlapping the exposed portions of the two tarsal plates, drawn together with a 5/0 Prolene suture. In our modification of the original technique described by McLaughlin (McLaughlin, 1950), for each eyelid, the suture is passed through a 4 mm section of silicone tube taken from a MINISETÒ Vein Infusion Set (Baxter Healthcare Pty Ltd, Old Toongabbie, Australia), which is used as a bolster (Fig. 2B). The sutures are removed after one week. All patients were routinely followed post-operatively, mostly as part of their cancer surveillance with an assessment of adequacy of eye closure and discomfort.
A 1.5 cm supra-tarsal incision is made and extended through the orbicularis oculi muscle, with care taken to avoid injury to the levator aponeurosis. A pocket is created over the tarsal plate, just sufficient to accommodate the gold weight. Early in the series, a 1 g weight was used routinely for all patients, but this was found to be too light in some male patients. We now routinely use a 1 g weight for females and a 1.2 g weight for males. The gold weights are custom made by a local goldsmith. They have a slight curvature to mirror the contour the globe (Fig. 1). The predrilled holes allow tarsal fixation, using 6/0 Prolene taking care not to penetrate the
Fig. 1. A 1.2 g gold weight showing a slight curvature to mirror the contour of the globe. The pre-drilled holes allow tarsal fixation.
Fig. 2. The McLaughlin lateral tarsorrhaphy with our modification involves excision near the lateral canthus of a 5 mm narrow triangular strip of the outer lid margin from the lower lid incorporating the eyelashes and adjacent skin, down to the tarsal plate. A corresponding narrow triangular strip of the inner lid margin of the upper lid is excised including the adjacent conjunctiva (A). The lateral extent of the lower lid is then tugged under the upper eyelid, overlapping the exposed portions of the two tarsal plates, drawn together with a 5/0 Prolene suture passed through two 4 mm silicone tubes used as bolsters (B).
S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
3. Results There were 46 male and 17 female patients with an average age of 65 (range, 29e88) years. Six patients had surgery to the eyelid alone under local anaesthesia. In a young patient in whom the facial nerve was lost at the skull base during excision of a large acoustic neuroma, insertion of a gold weight was performed under local anaesthesia upon referral (Fig. 3), followed by cross facial nerve grafting. The remaining 56 patients had more extensive facial reanimation procedures involving the middle and/or the lower thirds of the face under general anaesthesia (Fig. 4). Thirty-six patients had an immediate reanimation procedure either following sacrifice of the facial nerve trunk and/ or branch(es) during tumour excision (n ¼ 35) or repair of facial
e51
laceration involving the facial nerve, which was also repaired (n ¼ 1). Twenty-seven patients had a delayed procedure all of whom were referred from other services either following tumour excision (n ¼ 21) including failed attempts at reconstruction in one patient performed elsewhere or unresolved Bell’s palsy (n ¼ 3) or facial palsy due to complex craniofacial fractures (n ¼ 3). Of the patients who underwent immediate facial reanimation, the most common cause of facial palsy was sacrifice of the facial nerve involved by parotid tumour (n ¼ 35) with the majority being metastasis from cutaneous squamous cell carcinoma (n ¼ 25). Two other patients had recurrent pleomorphic adenoma previously treated by other services. One of these patients, a 40-year-old man, was referred following inadvertent facial nerve transection during
Fig. 3. A 33-year-old woman with complete right facial paralysis following resection of a large acoustic neuroma resulting in the loss of the facial nerve at the skull base (A). Lagophthalmos facial with corneal exposure despite the presence of Bell’s phenomenon in attempting eye closure (B). Six days after the initial tumour surgery, insertion of a 1 g gold weight to the upper eyelid was performed which was followed by cross facial nerve graft. Three weeks following gold weight insertion (C) achieving full eye closure (D).
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S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
Fig. 4. An 83-year-old man with metastatic squamous cell carcinoma to the right parotid with facial paralysis including eyebrow ptosis, paralytic lower lid ectropion, lagophthalmos, and to a lesser extent, weakness of the lower two-thirds of the face (A). The patient underwent a right radical parotidectomy, selective neck dissection, immediate facial reanimation and post-operative adjuvant radiotherapy. Facial reanimation included a browlift, insertion of a 1.2 g gold weight to the upper eyelid, lateral tarsorrhaphy, insertion of a conchal cartilage graft to the lower lid, temporalis muscle transfer with tensor fascia lata extension to the alar base, modiolus and upper lip, and a digastric muscle transfer. Results 22 months after the ablative and reconstructive surgery (B & C).
(incomplete) excision of a recurrent pleomorphic adenoma. Another patient, a 42-year-old man with a fourth time recurrent pleomorphic adenoma following previous excisions and radiotherapy, was referred for a recurrence involving the skull base and multiple dermal deposits. Radical parotidectomy with sacrifice of the facial nerve and immediate reanimation was performed on these two patients. The remaining patients had locally advanced primary parotid cancers such as muco-epidermoid carcinoma. Gold weight implantation was performed for all patients treated with a curative intent and a frail elderly patient who was treated palliatively for an advanced metastatic squamous cell carcinoma in the parotid and neck with complete facial palsy. In this patient the procedure was performed under local anaesthesia to manage the distressing exposure keratitis. In addition McLaughlan’s lateral tarsorrhaphy with our modification was also performed in all except three patients aged less than 45 years. The average follow-up was 32 (range 4e80) months. Sixteen patients died during the study period having survived an average of 17 (range 1e38) months following surgery. Fifteen of these patients had advanced parotid cancer (including the patient who was treated palliatively). The other patient who had suffered severe facial fractures having been kicked by a steer died of unrelated causes, aged 83 years. Nine (14%) patients had their gold weights replaced to achieve optimal weight, six had insufficient and three had excessive weight. The six patients who had insufficient weight underwent immediate facial reanimation following facial nerve sacrifice. All of these patients were males who underwent implantation with 1 g gold weights, early in the series. The three patients with excessive weight underwent delayed reconstruction. Two patients needed repositioning of their gold weights which became infected and were removed, and successfully re-inserted subsequently. Two young patients had the gold weights removed after anticipated facial nerve recovery following nerve grafting of the frontal and zygomatic branches of the facial nerve as part of full facial reanimation. Fifty-two (83%) patients had full eye closure. The remaining 11 patients had partial eye closure, three of whom needed to tape the eye at night to provide additional eye protection.
4. Discussion Cutaneous SCC of the head and neck metastasising to regional nodes (Mourouzis et al., 2009) is a significant problem presenting to our Centre in New Zealand (Brougham et al., 2011, in press). The parotid gland is a common nodal site for metastasis from cutaneous SCC of the head and neck. Facial palsy often results from the metastatic disease to the parotid and/or its treatment. The majority of the affected patients are elderly with limited life expectancy (Ch’ng et al., 2006, 2008) and are not suitable for immediate microsurgical reanimation. Gold weight implantation and lateral tarsorrhaphy are simple and safe procedures that prevent exposure keratitis resulting from facial nerve sacrifice or injury. Patients with facial paralysis have a widened palpebral aperture, often associated with lower lid laxity especially in older patients. Except in younger patients, we also perform a McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification to support the lower lid and to narrow the palpebral aperture which improves the mechanical efficiency of the upper lid closure. Most series report on delayed insertion of gold weights some time following ablative surgery. More recently, earlier implantation (within three months of nerve division) has been shown to be effective (Snyder et al., 2001). The aims of treatment of head and neck cancer are preservation/ restoration of quality of life, loco-regional control, and long term survival. Immediate facial reanimation should be performed at the time of ablative surgery when all structures are exposed. In our experience this only slightly increases the total operating time. Lai et al. (2002) report their results of parotidectomy for aggressive metastatic cutaneous malignancies. In cases that require sacrifice of the facial nerve, they either performed an immediate cable graft or make no attempt at reconstruction. Most of our patients who undergo radical parotidectomy for aggressive metastatic cutaneous malignancies are elderly with limited life expectancy. Nerve grafting has a limited role in these patients and we prefer other forms of reconstruction that achieve immediate restoration of facial function. In young patients who undergo sacrifice of the facial nerve trunk during parotid tumour ablation,
S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
nerve grafting between the facial nerve trunk and its branches is a treatment option. However, these patients universally develop distressing synkinesis (Rovak et al., 2004). We prefer to reanimate the upper, middle and lower thirds of the face separately, as described. In addition we also perform nerve grafting from the proximal facial nerve stump to the zygomatic and frontal branches. The gold weight inserted to the upper lid can be removed following nerve regeneration as was done in our two younger patients. Golio et al. (2007) have recently reviewed results of periocular reconstruction for facial nerve paralysis in cancer patients. They recommend that immediate reconstruction is not performed because of difficulties in assessing the amount of lid laxity and degree of lagophthalmos. They prefer to assess the patient in the upright position in the immediate post-operative period before deciding on the size of gold weight. Our experience shows that attempts to quantify the weight needed such as taping the weight on the upper eyelid pre-operatively, are fraught with inaccuracies. In our series we had to exchange six out of the 36 gold weights we inserted during immediate facial reanimation to achieve optimal eye closure. This compares well with the results of delayed gold weight implantation whereby a sub-optimal size is used in up to 30% of cases (MüllerJensen and Jansen, 1997). All of the six patients who required exchange of their gold weights were males who underwent implantation of 1 g gold weights, earlier in the series. We now routinely use 1 g for female and 1.2 g for male patients and achieve optimal eye closure for most of our patients. In addition, our approach allows immediate eye protection following ablative surgery. 5. Conclusion Sacrifice of the facial nerve during head and neck cancer surgery is devastating for the patient and immediate facial reanimation should be performed to preserve/restore the quality of life. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective way of achieving eye closure. Role of the funding source The authors did not receive any funding for this work. Conflict of interest All the authors do not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. References Biglioli F, Frigerio A, Antelitano L, Colletti G, Rabbiosi D, Brusati R: Deep-planes lift associated with free flap surgery for facial reanimation. J Craniomaxillofac Surg 39: 475e481, 2011
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Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E: Free flaps: outcomes and complications in head and neck reconstruction. J Craniomaxillofac Surg 37: 438e442, 2009 Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E: Successful salvage surgery after treatment failures with cross graft and free muscle transplant in facial reanimation. J Craniomaxillofac Surg 40: 185e189, 2012 Brougham ND, Dennett ER, Tan ST: Changing incidence of non-melanoma skin cancer in New Zealand. ANZ J Surg 81: 633e636, 2011 Brougham NDL, Dennett ER, Cameron R, Tan ST: Incidence and risk factors of metastasis for cutaneous squamous cell carcinoma. J Surg Oncol, in press. Ch’ng S, Lea RG, Brasch H, Tan ST: Parotid metastasis e an independent prognostic factor for head and neck cutaneous squamous cell carcinoma. J Plast Reconstr Aesth Surg 59: 1288e1293, 2006 Ch’ng S, Maitra A, Allison R, Chaplin JM, Gregor RT, Lea R, et al: Parotid and cervical nodal status predict prognosis for patients with head & neck metastatic cutaneous squamous cell carcinoma e a multicentre study of the New Zealand population. J Surg Oncol 98: 101e105, 2008 Golio D, De Martelaere S, Anderson J, Esmaeli B: Outcomes of periocular reconstruction for facial nerve paralysis in cancer patients. Plast Reconstr Surg 119: 1233e1237, 2007 Jobe R: A technique for lid loading in the management of the lagophthalmos of facial palsy. Plast Reconstr Surg 53: 29e32, 1974 Kartush J, Linstrom C, McCann P, Graham M: Early gold weight eyelid implantation for facial paralysis. Otolaryngol Head Neck Surg 103: 1016e1023, 1990 Lai SY, Weinstein GS, Chalian AA, Rosenthal DI, Weber RS: Parotidectomy in the treatment of aggressive cutaneous malignancies. Arch Otolaryngol Head Neck Surg 128: 521e526, 2002 Mühlbauer WD, Segeth H, Viessmann A: Restoration of lid function in facial palsy with permanent magnets. Eur J Plast Surg 1: 295e304, 1973 Morel-Fatio D, Lalardrie J: Palliative surgical treatment of facial paralysis. The palpebral spring. Plast Reconstr Surg 33: 446e456, 1964 May M: Paralyzed eyelids reanimated with a closed-eyelid spring. Laryngoscope 98: 382e385, 1988 McNeil J, Oh Y: An improved palpebral spring for the management of paralytic lagophthalmos. Ophthalmology 98: 715e719, 1991 May M: Gold weight and wire spring implants as alternatives to tarsorrhaphy. Arch Otolaryngol Head Neck Surg 113: 656e660, 1987 McLaughlin C: Epiphora in facial paralysis. Br J Plast Surg 3: 87e95, 1950 McLaughlin C: Surgical support in permanent facial paralysis. Plast Reconstr Surg 11: 302e314, 1953 Mourouzis C, Boynton A, Grant J, Umar T, Wilson A, Macpheson D, et al: Cutaneous head and neck SCCs and risk of nodal metastasis e UK experience. J Craniomaxillofac Surg 37: 443e447, 2009 Müller-Jensen K, Jansen M: 6jährige Erfahrung mit reversibler und operativer Oberlidbeschwerung beim Lagophthalmus. Der Ophthalmologe 94: 295e299, 1997 Rovak JM, Tung TH, Mackinnon SE: The surgical management of facial nerve injury. Semin Plast Surg 18: 23e29, 2004 Smellie GD: Restoration of the blinking reflex in facial palsy by a simple lid-load operation. Br J Plast Surg 19: 279e283, 1966 Snyder MC, Johnson PJ, Moore GF, Ogren FP: Early versus late gold weight implantation for rehabilitation of the paralyzed eyelid. Laryngoscope 111: 2109e2113, 2001 Terzis JK, Kyere SA: Experience with the gold weight and palpebral spring in the management of paralytic lagophthalmos. Plast Reconstr Surg 121: 806e815, 2008 Tulley P, Webb A, Chana JS, Tan ST, Hudson D, Grobbelaar AO, et al: Paralysis of the marginal mandibular branch of the facial nerve: treatment options. Br J Plast Surg 53: 378e385, 2000 Tan ST: Anterior belly of digastric muscle transfer: a useful technique in head and neck surgery. Head Neck 24: 947e954, 2002
Contents lists available at SciVerse ScienceDirect
Journal of Cranio-Maxillo-Facial Surgery journal homepage: www.jcmfs.com
Gold weight implantation and lateral tarsorrhaphy for upper eyelid paralysisq Swee T. Tan a, b, c, *, Jonathan J. Staiano a, Tinte Itinteang a, b, Benjamin C. McIntyre a, Craig A. MacKinnon a, David W. Glasson a a
Head & Neck and Skull Base Surgery/Oncology Programme, Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Wellington, New Zealand Gillies McIndoe Research Institute, Wellington, New Zealand c University of Otago, Wellington, New Zealand b
a r t i c l e i n f o
a b s t r a c t
Article history: Paper received 7 October 2011 Accepted 16 July 2012
Background: Upper eyelid paralysis leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness. Methods: Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy were identified from our prospective database and reviewed. Results: Sixty-three patients were identified, 36 of whom underwent immediate reanimation procedure either during cancer excision (n ¼ 35) or repair of facial laceration (n ¼ 1). Twenty-seven patients had a delayed procedure either following tumour excision (n ¼ 21) or unresolved Bell’s palsy (n ¼ 3), or facial palsy due to complex craniofacial fracture (n ¼ 3). Nine patients required revision to achieve optimal weight. Fifty-two patients had full eye closure. The remaining 11 patients had almost complete eye closure. Conclusions: Facial paralysis is devastating for the patient and immediate facial reanimation should be performed. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective in achieving eye closure. Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
Keywords: Gold weight Lagophthalmos Facial palsy Reanimation Immediate
1. Introduction Facial palsy is devastating with considerable cosmetic and functional concerns for the affected patients. Paralysis of the orbicularis oculi muscle leads to lagophthalmos with the risk of exposure keratitis, corneal ulceration and blindness. Artificial tears, lubricants, eye taping and tarsorrhaphy are useful but they are often inadequate for eye protection. More definitive techniques include the use of magnets (Mühlbauer et al., 1973), palpebral springs (Morel-Fatio and Lalardrie, 1964; May, 1988; McNeil and Oh, 1991; Terzis and Kyere, 2008) and gold weights (Smellie, 1966; Jobe, 1974; May, 1987; Kartush et al., 1990; Terzis and Kyere, 2008). A number of authors have recently published in this Journal advocating immediate facial reanimation by microvascular free flap surgery (Biglioli et al., 2011; Bianchi et al., 2009, 2012). However,
q Parts of this paper were presented at the Australian & New Zealand Head and Neck Cancer Society’s Annual Scientific Meeting, Brisbane, Australia, July 26e28, 2007 and the New Zealand Association of Plastic Surgeons’ Annual Scientific Meeting, Wellington, New Zealand, October 6, 2007. * Corresponding author. Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, Private bag 31-907, High Street, Lower Hutt, New Zealand. Tel.: þ64 4 587 2506; fax: þ64 4 587 2510. E-mail address: [email protected] (S.T. Tan).
the majority of our patients are elderly with cancer with limited life expectancy (Ch’ng et al., 2006, 2008). They prefer functional reanimation for immediate improvement in quality of life. Therefore dynamic reanimation procedures using local muscles are commonly used at our Centre, to achieve this aim. Gold weight implantation to the upper eyelid combined with our modified McLaughlin’s lateral tarsorrhaphy (McLaughlin, 1950) is the preferred method for managing lagophthalmos in our Centre. We present our experience with this approach. 2. Material and methods Consecutive patients undergoing gold weight implantation and/or lateral tarsorrhaphy in our Centre between March 2000 and September 2010 were identified from our prospectively maintained head and neck/skull base database and reviewed. 2.1. Management philosophy and approach All head and neck cancer patients were managed through the multi-disciplinary head and neck team setting. Immediate reanimation was performed following the ablative procedure in cases where the facial nerve and/or its branch(es) was paralysed or sacrificed because of tumour involvement. Delayed reconstruction
1010-5182/$ e see front matter Ó 2012 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jcms.2012.07.015
e50
S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
was performed for cases that were referred from other services following ablative surgery. Facial paralysis was categorised as involving the upper, middle and lower thirds of the face. In our Centre, the preferred method of reanimation of the upper third of the face is by gold weight implantation to the upper lid. Except in young patients, a McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification is also performed to optimise eye protection. A browlift is performed for brow ptosis if this is present. A temporalis muscle transfer with fascia lata extension (McLaughlin, 1953) is performed to reanimate the middle third (alar base, upper lip and modiolus), and an anterior belly of digastric muscle transfer for the paralysed lower lip (Tulley et al., 2000; Tan, 2002). In younger patients who undergo sacrifice of the facial nerve trunk, nerve grafting from the proximal facial nerve stump to the frontal and zygomatic branches is performed, in addition to the techniques described above for the upper, middle and lower face. In these patients the gold weight is removed following recovery of the orbicularis oculi muscle function. In young patients in whom the facial nerve is lost at the skull base (e.g., during excision of a large acoustic neuroma), insertion of a gold weight is performed under local anaesthesia upon referral, followed by cross facial nerve grafting. 2.2. Surgical technique
conjunctiva. The orbicularis oculi muscle is approximated with a 6/0 Vicryl and the skin is closed with a subcuticular 6/0 Prolene. Patients with facial paralysis have a wider palpebral aperture, often associated with lower lid laxity, especially in older patients. A McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification is performed to support the lower lid and to narrow the palpebral aperture, which improves the mechanical efficiency of the upper lid closure. This involves excision of a 5 mm narrow triangular strip of the outer margin of the lower eyelid incorporating the eyelashes and adjacent skin near the lateral canthus, down to the tarsal plate. A corresponding narrow triangular strip of the inner lid margin and adjacent conjunctiva from of the upper lid is also excised (Fig. 2A). The lateral extent of the lower lid is then tugged under the upper eyelid, overlapping the exposed portions of the two tarsal plates, drawn together with a 5/0 Prolene suture. In our modification of the original technique described by McLaughlin (McLaughlin, 1950), for each eyelid, the suture is passed through a 4 mm section of silicone tube taken from a MINISETÒ Vein Infusion Set (Baxter Healthcare Pty Ltd, Old Toongabbie, Australia), which is used as a bolster (Fig. 2B). The sutures are removed after one week. All patients were routinely followed post-operatively, mostly as part of their cancer surveillance with an assessment of adequacy of eye closure and discomfort.
A 1.5 cm supra-tarsal incision is made and extended through the orbicularis oculi muscle, with care taken to avoid injury to the levator aponeurosis. A pocket is created over the tarsal plate, just sufficient to accommodate the gold weight. Early in the series, a 1 g weight was used routinely for all patients, but this was found to be too light in some male patients. We now routinely use a 1 g weight for females and a 1.2 g weight for males. The gold weights are custom made by a local goldsmith. They have a slight curvature to mirror the contour the globe (Fig. 1). The predrilled holes allow tarsal fixation, using 6/0 Prolene taking care not to penetrate the
Fig. 1. A 1.2 g gold weight showing a slight curvature to mirror the contour of the globe. The pre-drilled holes allow tarsal fixation.
Fig. 2. The McLaughlin lateral tarsorrhaphy with our modification involves excision near the lateral canthus of a 5 mm narrow triangular strip of the outer lid margin from the lower lid incorporating the eyelashes and adjacent skin, down to the tarsal plate. A corresponding narrow triangular strip of the inner lid margin of the upper lid is excised including the adjacent conjunctiva (A). The lateral extent of the lower lid is then tugged under the upper eyelid, overlapping the exposed portions of the two tarsal plates, drawn together with a 5/0 Prolene suture passed through two 4 mm silicone tubes used as bolsters (B).
S.T. Tan et al. / Journal of Cranio-Maxillo-Facial Surgery 41 (2013) e49ee53
3. Results There were 46 male and 17 female patients with an average age of 65 (range, 29e88) years. Six patients had surgery to the eyelid alone under local anaesthesia. In a young patient in whom the facial nerve was lost at the skull base during excision of a large acoustic neuroma, insertion of a gold weight was performed under local anaesthesia upon referral (Fig. 3), followed by cross facial nerve grafting. The remaining 56 patients had more extensive facial reanimation procedures involving the middle and/or the lower thirds of the face under general anaesthesia (Fig. 4). Thirty-six patients had an immediate reanimation procedure either following sacrifice of the facial nerve trunk and/ or branch(es) during tumour excision (n ¼ 35) or repair of facial
e51
laceration involving the facial nerve, which was also repaired (n ¼ 1). Twenty-seven patients had a delayed procedure all of whom were referred from other services either following tumour excision (n ¼ 21) including failed attempts at reconstruction in one patient performed elsewhere or unresolved Bell’s palsy (n ¼ 3) or facial palsy due to complex craniofacial fractures (n ¼ 3). Of the patients who underwent immediate facial reanimation, the most common cause of facial palsy was sacrifice of the facial nerve involved by parotid tumour (n ¼ 35) with the majority being metastasis from cutaneous squamous cell carcinoma (n ¼ 25). Two other patients had recurrent pleomorphic adenoma previously treated by other services. One of these patients, a 40-year-old man, was referred following inadvertent facial nerve transection during
Fig. 3. A 33-year-old woman with complete right facial paralysis following resection of a large acoustic neuroma resulting in the loss of the facial nerve at the skull base (A). Lagophthalmos facial with corneal exposure despite the presence of Bell’s phenomenon in attempting eye closure (B). Six days after the initial tumour surgery, insertion of a 1 g gold weight to the upper eyelid was performed which was followed by cross facial nerve graft. Three weeks following gold weight insertion (C) achieving full eye closure (D).
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Fig. 4. An 83-year-old man with metastatic squamous cell carcinoma to the right parotid with facial paralysis including eyebrow ptosis, paralytic lower lid ectropion, lagophthalmos, and to a lesser extent, weakness of the lower two-thirds of the face (A). The patient underwent a right radical parotidectomy, selective neck dissection, immediate facial reanimation and post-operative adjuvant radiotherapy. Facial reanimation included a browlift, insertion of a 1.2 g gold weight to the upper eyelid, lateral tarsorrhaphy, insertion of a conchal cartilage graft to the lower lid, temporalis muscle transfer with tensor fascia lata extension to the alar base, modiolus and upper lip, and a digastric muscle transfer. Results 22 months after the ablative and reconstructive surgery (B & C).
(incomplete) excision of a recurrent pleomorphic adenoma. Another patient, a 42-year-old man with a fourth time recurrent pleomorphic adenoma following previous excisions and radiotherapy, was referred for a recurrence involving the skull base and multiple dermal deposits. Radical parotidectomy with sacrifice of the facial nerve and immediate reanimation was performed on these two patients. The remaining patients had locally advanced primary parotid cancers such as muco-epidermoid carcinoma. Gold weight implantation was performed for all patients treated with a curative intent and a frail elderly patient who was treated palliatively for an advanced metastatic squamous cell carcinoma in the parotid and neck with complete facial palsy. In this patient the procedure was performed under local anaesthesia to manage the distressing exposure keratitis. In addition McLaughlan’s lateral tarsorrhaphy with our modification was also performed in all except three patients aged less than 45 years. The average follow-up was 32 (range 4e80) months. Sixteen patients died during the study period having survived an average of 17 (range 1e38) months following surgery. Fifteen of these patients had advanced parotid cancer (including the patient who was treated palliatively). The other patient who had suffered severe facial fractures having been kicked by a steer died of unrelated causes, aged 83 years. Nine (14%) patients had their gold weights replaced to achieve optimal weight, six had insufficient and three had excessive weight. The six patients who had insufficient weight underwent immediate facial reanimation following facial nerve sacrifice. All of these patients were males who underwent implantation with 1 g gold weights, early in the series. The three patients with excessive weight underwent delayed reconstruction. Two patients needed repositioning of their gold weights which became infected and were removed, and successfully re-inserted subsequently. Two young patients had the gold weights removed after anticipated facial nerve recovery following nerve grafting of the frontal and zygomatic branches of the facial nerve as part of full facial reanimation. Fifty-two (83%) patients had full eye closure. The remaining 11 patients had partial eye closure, three of whom needed to tape the eye at night to provide additional eye protection.
4. Discussion Cutaneous SCC of the head and neck metastasising to regional nodes (Mourouzis et al., 2009) is a significant problem presenting to our Centre in New Zealand (Brougham et al., 2011, in press). The parotid gland is a common nodal site for metastasis from cutaneous SCC of the head and neck. Facial palsy often results from the metastatic disease to the parotid and/or its treatment. The majority of the affected patients are elderly with limited life expectancy (Ch’ng et al., 2006, 2008) and are not suitable for immediate microsurgical reanimation. Gold weight implantation and lateral tarsorrhaphy are simple and safe procedures that prevent exposure keratitis resulting from facial nerve sacrifice or injury. Patients with facial paralysis have a widened palpebral aperture, often associated with lower lid laxity especially in older patients. Except in younger patients, we also perform a McLaughlin lateral tarsorrhaphy (McLaughlin, 1950) with our modification to support the lower lid and to narrow the palpebral aperture which improves the mechanical efficiency of the upper lid closure. Most series report on delayed insertion of gold weights some time following ablative surgery. More recently, earlier implantation (within three months of nerve division) has been shown to be effective (Snyder et al., 2001). The aims of treatment of head and neck cancer are preservation/ restoration of quality of life, loco-regional control, and long term survival. Immediate facial reanimation should be performed at the time of ablative surgery when all structures are exposed. In our experience this only slightly increases the total operating time. Lai et al. (2002) report their results of parotidectomy for aggressive metastatic cutaneous malignancies. In cases that require sacrifice of the facial nerve, they either performed an immediate cable graft or make no attempt at reconstruction. Most of our patients who undergo radical parotidectomy for aggressive metastatic cutaneous malignancies are elderly with limited life expectancy. Nerve grafting has a limited role in these patients and we prefer other forms of reconstruction that achieve immediate restoration of facial function. In young patients who undergo sacrifice of the facial nerve trunk during parotid tumour ablation,
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nerve grafting between the facial nerve trunk and its branches is a treatment option. However, these patients universally develop distressing synkinesis (Rovak et al., 2004). We prefer to reanimate the upper, middle and lower thirds of the face separately, as described. In addition we also perform nerve grafting from the proximal facial nerve stump to the zygomatic and frontal branches. The gold weight inserted to the upper lid can be removed following nerve regeneration as was done in our two younger patients. Golio et al. (2007) have recently reviewed results of periocular reconstruction for facial nerve paralysis in cancer patients. They recommend that immediate reconstruction is not performed because of difficulties in assessing the amount of lid laxity and degree of lagophthalmos. They prefer to assess the patient in the upright position in the immediate post-operative period before deciding on the size of gold weight. Our experience shows that attempts to quantify the weight needed such as taping the weight on the upper eyelid pre-operatively, are fraught with inaccuracies. In our series we had to exchange six out of the 36 gold weights we inserted during immediate facial reanimation to achieve optimal eye closure. This compares well with the results of delayed gold weight implantation whereby a sub-optimal size is used in up to 30% of cases (MüllerJensen and Jansen, 1997). All of the six patients who required exchange of their gold weights were males who underwent implantation of 1 g gold weights, earlier in the series. We now routinely use 1 g for female and 1.2 g for male patients and achieve optimal eye closure for most of our patients. In addition, our approach allows immediate eye protection following ablative surgery. 5. Conclusion Sacrifice of the facial nerve during head and neck cancer surgery is devastating for the patient and immediate facial reanimation should be performed to preserve/restore the quality of life. We have demonstrated that gold weight implantation and lateral tarsorrhaphy are simple and effective way of achieving eye closure. Role of the funding source The authors did not receive any funding for this work. Conflict of interest All the authors do not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. References Biglioli F, Frigerio A, Antelitano L, Colletti G, Rabbiosi D, Brusati R: Deep-planes lift associated with free flap surgery for facial reanimation. J Craniomaxillofac Surg 39: 475e481, 2011
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