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Surgical correction of lower eyelid paralysis with suture screw anchors
Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1598e1601
Surgical correction of lower eyelid paralysis with suture screw anchors ´mez-Ruiz Bernardo Hontanilla*, Raul Go Department of Plastic and Reconstructive Surgery, Clı´nica Universitaria, Universidad de Navarra, C/ Pı´o XII, 36, 31008 Pamplona, Spain Received 21 April 2008; accepted 15 July 2008
KEYWORDS Facial paralysis; Ectropion; Epiphora; Screw anchor
Summary Among the major disorders of the lower eyelid due to peripheral facial paralysis are lagophthalmos, eyelid ptosis and ectropion, with or without epiphora. There are several surgical techniques for correcting ectropion and lower eyelid ptosis. This article describes a modification of the classic technique of suspension using tendons, which consists of anchoring the tendon to the frontal apophysis of the maxillary bone and external orbital bone with suture screw anchors. Using the described technique, we obtained significant improvement of epiphora. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
One of the most frequent peripheral facial paralysis disorders is the presence of lagophthalmos1 and ectropion.2 This latter alteration leads to inappropriate contact between the lower tear duct and the eyeball. This situation causes epiphora, which may be increased by the aberrant reinnervation of the lachrymal gland. Various surgical techniques are used to correct this condition, including tarsorrhaphy,3 external canthoplasty4 and canthopexy.5 In external canthoplasty, the external canthal ligament is taken out and then re-inserted higher in the periosteum of the frontal bone to ensure that the tendon is more stable. The use of a tendinous strap,6 or less frequently, alloplastic material,7 in the free edge of the lower lid is a common practice. The objective of this procedure is to support the
lower eyelid against the eyeball to avoid epiphora. Alloplastic material is not recommended because of the high risk of infection and extrusion.6 Long-term studies show that anchoring the tendon strap to the internal canthal ligament usually produces a loss of the graft tension so that the ectropion often reappears, and the epiphora worsens due to the loss of contact between the tear duct and the sclera.2 In this article, we describe a modification of the classical technique of suspension using tendons. Anchoring of the tendon to the frontal apophysis of the maxillary bone and external orbital bone is presented as an effective procedure to improve epiphora.
* Corresponding author. Tel.: þ34 948 255400; fax: þ34 948 296500. E-mail address: [email protected] (B. Hontanilla).
We selected 17 patients aged between 55 and 75 years (12 men and 5 women) diagnosed with facial paralysis, including ectropion and epiphora. No patients had
Materials and methods
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.07.026
Surgical correction of lower eyelid undergone any dynamic procedures such as cross-facial nerve graft or direct neurotisation of the orbicular muscle. All patients included in this study had previously been operated on to resolve the lagophthalmos by implanting a gold weight, and no patients presented exposure keratitis. The average age of the patients was 68 years. All these patients were treated by suturing two 2-mm screw anchors (Orthomed, Paris, France). The use of suture screw anchors requires three surgical incisions (Figure 1A). The first incision is made 0.5 cm above the medial canthal ligament, the second is located laterally to the external canthus and finally the last incision is performed 1 cm lateral to the upper eyelid in the external orbital bone. The surgeon makes a tunnel in the lower eyelid using a keith 14F needle. The tendon graft is inserted along the tunnel (Figure 1B and C). Then, the tendon (the palmar longus tendon or the fascia lata) is attached to the frontal apophysis of the maxillary bone (0.5 cm above the medial canthus). Once the tendon has been attached to the frontal apophysis, the lateral portion of the tendon is attached also to the external orbital bone with the second anchor (Figure 1D). We move up the anchor point of the lower eyelid, especially in the medial portion, obtaining better contact between the tear duct and the sclera. This contact facilitates the drainage of the tear and prevents epiphora. Finally, the free border of the lower eyelid should be located 1.5 mm above the pupil with more tension than required (Figure 2) in anticipation of lowering of the lower eyelid over the following few weeks.
1599 The results obtained in the screw anchors group (n Z 17) are compared to a group treated with the classic suspension method using tendons without screw anchoring (n Z 41). The distance between the inferior iris border and the free border of the lower eyelid is measured using the Facial Clima Sistem8 2 years after surgery. The mean value in both groups is statistically analysed using Student’s t-test for means. The variances were compared using Levene’s test for variances.
Results The 17 patients treated by the technique described in this article presented adequate resolution of ectropion and epiphora in the postoperative evaluations. There was no recurrence of ectropion in the group of patients treated with two screw anchors after 2 years of follow-up. A surgical revision was necessary in two patients to correct hypertension detected 1 month postoperatively. Lagophthalmos and epiphora were not found in any patient after surgical repair. The patients were asked about any interference of the lower eyelid in the visual field, and no patients were found to have problems of this kind (Figure 3). The 41 patients treated by classic suspension using tendons without screw anchors were evaluated, and epiphora was found in 10 patients (25%) 2 years after surgery. No patients in either group presented local infection due to communication with the nasal cavity, and no
Figure 1 A shows the surgical incisions. B and C. The tendon is inserted along the tunnel. D. The tendon is attached to the frontal apophysis of the maxillary bone and the external orbital bone.
1600
B. Hontanilla, R. Go ´mez-Ruiz
Figure 2 A shows the screw anchorage in the frontal apophysis of the maxillary bone. B. The tendinous strap is introduced along the lower eyelid tunnel, and the suture is inserted with the screw. C. The tendinous strap is introduced in the lateral incision over the orbital bone. D. Lateral anchorage of the tendon to the orbital bone as shown in A.
chronic reactions that required removal of the anchors were detected. Statistically significant differences were obtained 2 years after surgery. The mean difference in the distance between the inferior iris border and the free border of the lower eyelid between the two groups was 1.08 (95% CI: 0.86e1.29), and this difference was statistically significant (p < 0.0001). The standard deviation with the new technique proposed here was lower than that obtained using classic suspension techniques, and this difference was also significant (p Z 0.001) (Tables 1 and 2).
Discussion Different techniques have been described for the surgical treatment of ectropion and epiphora in patients with facial paralysis. Among these, tarsorrhaphy,3 canthoplasty4 and canthopexy5 were the most commonly used, as mentioned above. Tarsorrhaphy can interfere with the temporary field of vision, and external canthoplasty offers a poor aesthetic result, as it closes the lateral portion of the palpebral opening. Finally, in canthopexy, the recurrence of epiphora is frequent because the tear duct loses contact with the
Figure 3 A. Preoperative image of the eye showing the paralysed lower eyelid. B. Preoperative image when the eye is closed. C. One year postoperative image of the repaired eyelid with a tendinous strap fixed to the maxillary and frontal bones with suture screws. D. Postoperative image when the eye is closed.
Surgical correction of lower eyelid
1601
Technique
N
Mean (mm)
Std. Deviation
Screw anchors Classical suspension
17 41
0,2824 1,3585
0,18109 0,41772
eyeball due to the lateral traction to which the eyelid is submitted. Several techniques using suture anchors have been described. On the one hand, Hayashi et al.9 have described a technique using just one anchor with 3/0 non-absorbable sutures. These authors do not use tendons to support the lower eyelid, but a muscle transfer or hypoglossal-facial nerve was performed in five and one of the seven patients used by theses authors, respectively. The anchor is inserted in a hole at the frontal process of the maxillary bone, and the sutures are anchored to the periosteum of the zygoma after passing though the lower eyelid. Terzis et al.10 use a tendinous graft which is fixated medially and only anchored laterally using the Mitek system. In their study, the authors used other procedures such as free muscle transfers, direct neurotisation and cross-facial nerve to correct the ectropion, which could enhance the long-term results achieved using the Mitek system. Thus, the mini-tendon graft is presented as a supplementary technique in combination with dynamic techniques. The new technique described in our article uses two screw anchors, medially and laterally, which allows us to displace both anchorage points of the lower eyelid in the cranial direction. This displacement favours contact between the tear duct of the lower eyelid and the eyeball to facilitate lachrymal drainage. The increased elevation, especially in the medial portion of the lower eyelid, prevents the reappearance of the ectropion and epiphora. Moreover, in our study, no dynamic procedures were performed in any patients which could modify the results obtained when the anchoring system is used. Thus, we present a technique with good results using an isolated procedure.
Acknowlegements We thank Mrs. Monica Mendigan ˜a and Mrs. Tatiana Acosta for their help in the preparation of the manuscript.
Table 2 Box-plot of distance between the inferior iris border and the free border of the lower eyelid by using the Facial Clima system 2,50 2,00
Distance mm
Table 1 Table showing the mean and standard deviation between groups. The distance between the inferior iris border and the free border of the lower eyelid is measured with the Facial Clima
1,50 1,00 0,50 0,00 Screw anchores
Classical suspension
Technique
References 1. Hontanilla B. Weight measurement of upper eyelid gold implants for lagophthalmos in facial paralysis. Plast Reconstr Surg 2001;108:1539e43. 2. Hontanilla B, Auba ´ C. Surgical approach the correction of the paralysed eyelid in facial paralysis. Cir Pla´st Iberlatinamer 2004;30:275e84. 3. Warren AG. A method of medial tarsorraphy for correction of lagophtalmos and ectropion. Lepr Rev 1966;37:217e8. 4. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg 1997;100:1396e405. 5. Frueh BR, Su CS. Medial tarsal suspensio ´n: a method of elevating the medial lower eyelid. Ophthal Plast Reconstr Surg 2002;18:133e7. 6. Qian JG, Wang XJ, Wu Y. Severe cicatrical ectropion: repair with a large advancement flap and autologous fascia sling. J Plast Reconstr Aesthet Surg 2006;59:878e81. 7. Daigeler R, Bohmert H. Masseterplasty in facial paralysis. Use of the Gore-Tex (PTFE) soft tissue patch as a tendon rein. Fortschr Med 1986;104:304e6. 8. Hontanilla B, Auba ´ C. Automatic three-dimensional quantitative analysis for evaluation of facial movement. J Plast Reconstr Aesthet Surg 2008;61:18e30. 9. Hayashi A, Maruyama Y, Okada E, et al. Use of a suture anchor for correction of ectropion in facial paralysis. Plast Reconstr Surg 2005;115:234e9. 10. Terzis JK, Kyere SA. Minitendon graft transfer for suspension of the paralyzed lower eyelid: our experience. Plast Reconstr Surg 2008;121:1206e16.
Surgical correction of lower eyelid paralysis with suture screw anchors ´mez-Ruiz Bernardo Hontanilla*, Raul Go Department of Plastic and Reconstructive Surgery, Clı´nica Universitaria, Universidad de Navarra, C/ Pı´o XII, 36, 31008 Pamplona, Spain Received 21 April 2008; accepted 15 July 2008
KEYWORDS Facial paralysis; Ectropion; Epiphora; Screw anchor
Summary Among the major disorders of the lower eyelid due to peripheral facial paralysis are lagophthalmos, eyelid ptosis and ectropion, with or without epiphora. There are several surgical techniques for correcting ectropion and lower eyelid ptosis. This article describes a modification of the classic technique of suspension using tendons, which consists of anchoring the tendon to the frontal apophysis of the maxillary bone and external orbital bone with suture screw anchors. Using the described technique, we obtained significant improvement of epiphora. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
One of the most frequent peripheral facial paralysis disorders is the presence of lagophthalmos1 and ectropion.2 This latter alteration leads to inappropriate contact between the lower tear duct and the eyeball. This situation causes epiphora, which may be increased by the aberrant reinnervation of the lachrymal gland. Various surgical techniques are used to correct this condition, including tarsorrhaphy,3 external canthoplasty4 and canthopexy.5 In external canthoplasty, the external canthal ligament is taken out and then re-inserted higher in the periosteum of the frontal bone to ensure that the tendon is more stable. The use of a tendinous strap,6 or less frequently, alloplastic material,7 in the free edge of the lower lid is a common practice. The objective of this procedure is to support the
lower eyelid against the eyeball to avoid epiphora. Alloplastic material is not recommended because of the high risk of infection and extrusion.6 Long-term studies show that anchoring the tendon strap to the internal canthal ligament usually produces a loss of the graft tension so that the ectropion often reappears, and the epiphora worsens due to the loss of contact between the tear duct and the sclera.2 In this article, we describe a modification of the classical technique of suspension using tendons. Anchoring of the tendon to the frontal apophysis of the maxillary bone and external orbital bone is presented as an effective procedure to improve epiphora.
* Corresponding author. Tel.: þ34 948 255400; fax: þ34 948 296500. E-mail address: [email protected] (B. Hontanilla).
We selected 17 patients aged between 55 and 75 years (12 men and 5 women) diagnosed with facial paralysis, including ectropion and epiphora. No patients had
Materials and methods
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.07.026
Surgical correction of lower eyelid undergone any dynamic procedures such as cross-facial nerve graft or direct neurotisation of the orbicular muscle. All patients included in this study had previously been operated on to resolve the lagophthalmos by implanting a gold weight, and no patients presented exposure keratitis. The average age of the patients was 68 years. All these patients were treated by suturing two 2-mm screw anchors (Orthomed, Paris, France). The use of suture screw anchors requires three surgical incisions (Figure 1A). The first incision is made 0.5 cm above the medial canthal ligament, the second is located laterally to the external canthus and finally the last incision is performed 1 cm lateral to the upper eyelid in the external orbital bone. The surgeon makes a tunnel in the lower eyelid using a keith 14F needle. The tendon graft is inserted along the tunnel (Figure 1B and C). Then, the tendon (the palmar longus tendon or the fascia lata) is attached to the frontal apophysis of the maxillary bone (0.5 cm above the medial canthus). Once the tendon has been attached to the frontal apophysis, the lateral portion of the tendon is attached also to the external orbital bone with the second anchor (Figure 1D). We move up the anchor point of the lower eyelid, especially in the medial portion, obtaining better contact between the tear duct and the sclera. This contact facilitates the drainage of the tear and prevents epiphora. Finally, the free border of the lower eyelid should be located 1.5 mm above the pupil with more tension than required (Figure 2) in anticipation of lowering of the lower eyelid over the following few weeks.
1599 The results obtained in the screw anchors group (n Z 17) are compared to a group treated with the classic suspension method using tendons without screw anchoring (n Z 41). The distance between the inferior iris border and the free border of the lower eyelid is measured using the Facial Clima Sistem8 2 years after surgery. The mean value in both groups is statistically analysed using Student’s t-test for means. The variances were compared using Levene’s test for variances.
Results The 17 patients treated by the technique described in this article presented adequate resolution of ectropion and epiphora in the postoperative evaluations. There was no recurrence of ectropion in the group of patients treated with two screw anchors after 2 years of follow-up. A surgical revision was necessary in two patients to correct hypertension detected 1 month postoperatively. Lagophthalmos and epiphora were not found in any patient after surgical repair. The patients were asked about any interference of the lower eyelid in the visual field, and no patients were found to have problems of this kind (Figure 3). The 41 patients treated by classic suspension using tendons without screw anchors were evaluated, and epiphora was found in 10 patients (25%) 2 years after surgery. No patients in either group presented local infection due to communication with the nasal cavity, and no
Figure 1 A shows the surgical incisions. B and C. The tendon is inserted along the tunnel. D. The tendon is attached to the frontal apophysis of the maxillary bone and the external orbital bone.
1600
B. Hontanilla, R. Go ´mez-Ruiz
Figure 2 A shows the screw anchorage in the frontal apophysis of the maxillary bone. B. The tendinous strap is introduced along the lower eyelid tunnel, and the suture is inserted with the screw. C. The tendinous strap is introduced in the lateral incision over the orbital bone. D. Lateral anchorage of the tendon to the orbital bone as shown in A.
chronic reactions that required removal of the anchors were detected. Statistically significant differences were obtained 2 years after surgery. The mean difference in the distance between the inferior iris border and the free border of the lower eyelid between the two groups was 1.08 (95% CI: 0.86e1.29), and this difference was statistically significant (p < 0.0001). The standard deviation with the new technique proposed here was lower than that obtained using classic suspension techniques, and this difference was also significant (p Z 0.001) (Tables 1 and 2).
Discussion Different techniques have been described for the surgical treatment of ectropion and epiphora in patients with facial paralysis. Among these, tarsorrhaphy,3 canthoplasty4 and canthopexy5 were the most commonly used, as mentioned above. Tarsorrhaphy can interfere with the temporary field of vision, and external canthoplasty offers a poor aesthetic result, as it closes the lateral portion of the palpebral opening. Finally, in canthopexy, the recurrence of epiphora is frequent because the tear duct loses contact with the
Figure 3 A. Preoperative image of the eye showing the paralysed lower eyelid. B. Preoperative image when the eye is closed. C. One year postoperative image of the repaired eyelid with a tendinous strap fixed to the maxillary and frontal bones with suture screws. D. Postoperative image when the eye is closed.
Surgical correction of lower eyelid
1601
Technique
N
Mean (mm)
Std. Deviation
Screw anchors Classical suspension
17 41
0,2824 1,3585
0,18109 0,41772
eyeball due to the lateral traction to which the eyelid is submitted. Several techniques using suture anchors have been described. On the one hand, Hayashi et al.9 have described a technique using just one anchor with 3/0 non-absorbable sutures. These authors do not use tendons to support the lower eyelid, but a muscle transfer or hypoglossal-facial nerve was performed in five and one of the seven patients used by theses authors, respectively. The anchor is inserted in a hole at the frontal process of the maxillary bone, and the sutures are anchored to the periosteum of the zygoma after passing though the lower eyelid. Terzis et al.10 use a tendinous graft which is fixated medially and only anchored laterally using the Mitek system. In their study, the authors used other procedures such as free muscle transfers, direct neurotisation and cross-facial nerve to correct the ectropion, which could enhance the long-term results achieved using the Mitek system. Thus, the mini-tendon graft is presented as a supplementary technique in combination with dynamic techniques. The new technique described in our article uses two screw anchors, medially and laterally, which allows us to displace both anchorage points of the lower eyelid in the cranial direction. This displacement favours contact between the tear duct of the lower eyelid and the eyeball to facilitate lachrymal drainage. The increased elevation, especially in the medial portion of the lower eyelid, prevents the reappearance of the ectropion and epiphora. Moreover, in our study, no dynamic procedures were performed in any patients which could modify the results obtained when the anchoring system is used. Thus, we present a technique with good results using an isolated procedure.
Acknowlegements We thank Mrs. Monica Mendigan ˜a and Mrs. Tatiana Acosta for their help in the preparation of the manuscript.
Table 2 Box-plot of distance between the inferior iris border and the free border of the lower eyelid by using the Facial Clima system 2,50 2,00
Distance mm
Table 1 Table showing the mean and standard deviation between groups. The distance between the inferior iris border and the free border of the lower eyelid is measured with the Facial Clima
1,50 1,00 0,50 0,00 Screw anchores
Classical suspension
Technique
References 1. Hontanilla B. Weight measurement of upper eyelid gold implants for lagophthalmos in facial paralysis. Plast Reconstr Surg 2001;108:1539e43. 2. Hontanilla B, Auba ´ C. Surgical approach the correction of the paralysed eyelid in facial paralysis. Cir Pla´st Iberlatinamer 2004;30:275e84. 3. Warren AG. A method of medial tarsorraphy for correction of lagophtalmos and ectropion. Lepr Rev 1966;37:217e8. 4. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty: techniques and indications. Plast Reconstr Surg 1997;100:1396e405. 5. Frueh BR, Su CS. Medial tarsal suspensio ´n: a method of elevating the medial lower eyelid. Ophthal Plast Reconstr Surg 2002;18:133e7. 6. Qian JG, Wang XJ, Wu Y. Severe cicatrical ectropion: repair with a large advancement flap and autologous fascia sling. J Plast Reconstr Aesthet Surg 2006;59:878e81. 7. Daigeler R, Bohmert H. Masseterplasty in facial paralysis. Use of the Gore-Tex (PTFE) soft tissue patch as a tendon rein. Fortschr Med 1986;104:304e6. 8. Hontanilla B, Auba ´ C. Automatic three-dimensional quantitative analysis for evaluation of facial movement. J Plast Reconstr Aesthet Surg 2008;61:18e30. 9. Hayashi A, Maruyama Y, Okada E, et al. Use of a suture anchor for correction of ectropion in facial paralysis. Plast Reconstr Surg 2005;115:234e9. 10. Terzis JK, Kyere SA. Minitendon graft transfer for suspension of the paralyzed lower eyelid: our experience. Plast Reconstr Surg 2008;121:1206e16.