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Surgical correction of lower eyelid paralysiswith suture screw anchors

Bernardo Hontanilla*, Raul Gomez-Ruiz

Department of Plastic and Reconstructive Surgery, Clnica Universitaria, Universidad de Navarra,C/ Po XII, 36, 31008 Pamplona, Spain

Received 21 April 2008; accepted 15 July 2008

KEYWORDSFacial 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 improve-

ment of epiphora.

2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

One of the most frequent peripheral facial paralysis disor-ders is the presence of lagophthalmos1 and ectropion.2 Thislatter alteration leads to inappropriate contact betweenthe lower tear duct and the eyeball. This situation causesepiphora, which may be increased by the aberrant re-innervation of the lachrymal gland. Various surgical tech-niquesare used to correct this condition, including tarsor-rhaphy,3 external canthoplasty4 and canthopexy.5 In

external canthoplasty, the external canthal ligament istaken out and then re-inserted higher in the periosteum ofthe frontal bone to ensure that the tendon is more stable.The use ofa tendinous strap,6 or less frequently, alloplasticmaterial,7 in the free edge of the lower lid is a commonpractice. The objective of this procedure is to support the

lower eyelid against the eyeball to avoid epiphora. Allo-plastic material is not recommended because of the highrisk of infection and extrusion.6 Long-term studies showthat anchoring the tendon strap to the internal canthalligament usually produces a loss of the graft tension so thatthe ectropion often reappears, and the epiphora worsensdue to the loss of contact between the tear duct and thesclera.2 In this article, we describe a modification of the

classical technique of suspension using tendons. Anchoringof the tendon to the frontal apophysis of the maxillary boneand external orbital bone is presented as an effectiveprocedure to improve epiphora.

Materials and methods

We selected 17 patients aged between 55 and 75 years (12men and 5 women) diagnosed with facial paralysis,including ectropion and epiphora. No patients had

* Corresponding author. Tel.: 34 948 255400; fax: 34 948296500.

E-mail address: bhontanill@unav.es(B. Hontanilla).

1748-6815/$- seefront matter2008BritishAssociationofPlastic,Reconstructiveand AestheticSurgeons. Publishedby ElsevierLtd.Allrightsreserved.doi:10.1016/j.bjps.2008.07.026

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 1598e1601

mailto:bhontanill@unav.esmailto:bhontanill@unav.es

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undergone any dynamic procedures such as cross-facialnerve graft or direct neurotisation of the orbicular muscle.All patients included in this study had previously beenoperated on to resolve the lagophthalmos by implantinga gold weight, and no patients presented exposure kera-titis. The average age of the patients was 68 years. Allthese patients were treated by suturing two 2-mm screwanchors (Orthomed, Paris, France). The use of suture screw

anchors requires three surgical incisions (Figure 1A). Thefirst incision is made 0.5 cm above the medial canthalligament, the second is located laterally to the externalcanthus and finally the last incision is performed 1 cmlateral to the upper eyelid in the external orbital bone. Thesurgeon makes a tunnel in the lower eyelid using a keith 14Fneedle. The tendon graft is inserted along the tunnel(Figure 1B and C). Then, the tendon (the palmar longustendon or the fascia lata) is attached to the frontalapophysis of the maxillary bone (0.5 cm above the medialcanthus). Once the tendon has been attached to the frontalapophysis, the lateral portion of the tendon is attached alsoto 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 bettercontact between the tear duct and the sclera. This contactfacilitates the drainage of the tear and prevents epiphora.Finally, the free border of the lower eyelid should belocated 1.5 mm above the pupil with more tension thanrequired (Figure 2) in anticipation of lowering of the lowereyelid over the following few weeks.

The results obtained in the screw anchors group (nZ 17)are compared to a group treated with the classic suspensionmethod using tendons without screw anchoring (nZ 41).The distance between the inferior iris border and the freeborder of the lower eyelid is measured using the FacialClima Sistem8 2 years after surgery. The mean value in bothgroups is statistically analysed using Students t-test formeans. The variances were compared using Levenes test

for variances.

Results

The 17 patients treated by the technique described in thisarticle presented adequate resolution of ectropion andepiphora in the postoperative evaluations. There was norecurrence of ectropion in the group of patients treatedwith two screw anchors after 2 years of follow-up.A surgical revision was necessary in two patients to correcthypertension detected 1 month postoperatively. Lagoph-thalmos and epiphora were not found in any patient aftersurgical repair. The patients were asked about any inter-

ference of the lower eyelid in the visual field, and nopatients were found to have problems of this kind(Figure 3). The 41 patients treated by classic suspensionusing tendons without screw anchors were evaluated, andepiphora was found in 10 patients (25%) 2 years aftersurgery. No patients in either group presented local infec-tion 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.

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chronic reactions that required removal of the anchorswere detected.

Statistically significant differences were obtained 2years after surgery. The mean difference in the distancebetween the inferior iris border and the free border of thelower eyelid between the two groups was 1.08 (95% CI:

0.86e

1.29), and this difference was statistically significant(p< 0.0001). The standard deviation with the new tech-nique proposed here was lower than that obtained usingclassic suspension techniques, and this difference was alsosignificant (pZ 0.001) (Tables 1 and 2).

Discussion

Different techniques have been described for the surgicaltreatment of ectropion and epiphora in patients withfacialparalysis. Among these, tarsorrhaphy,3 canthoplasty4 andcanthopexy5 were the most commonly used, as mentioned

above. Tarsorrhaphy can interfere with the temporary fieldof vision, and external canthoplasty offers a poor aestheticresult, as it closes the lateral portion of the palpebralopening. Finally, in canthopexy, the recurrence of epiphorais frequent because the tear duct loses contact with the

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 overthe orbital bone. D. Lateral anchorage of the tendon to the orbital bone as shown in A.

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.

1600 B. Hontanilla, R. Gomez-Ruiz

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eyeball due to the lateral traction to which the eyelid issubmitted.

Several techniques using suture anchors have beendescribed. On the one hand, Hayashi et al.9 have describeda technique using just one anchor with 3/0 non-absorbablesutures. These authors do not use tendons to support thelower eyelid, but a muscle transfer or hypoglossal-facialnerve was performed in five and one of the seven patientsused by theses authors, respectively. The anchor is inser-ted in a hole at the frontal process of the maxillary bone,and the sutures are anchored to the periosteum of thezygoma after passing though the lower eyelid. Terziset al.10 use a tendinous graft which is fixated medially andonly anchored laterally using the Mitek system. In theirstudy, the authors used other procedures such as freemuscle transfers, direct neurotisation and cross-facialnerve to correct the ectropion, which could enhance thelong-term results achieved using the Mitek system. Thus,the mini-tendon graft is presented as a supplementarytechnique in combination with dynamic techniques. Thenew technique described in our article uses two screwanchors, medially and laterally, which allows us todisplace both anchorage points of the lower eyelid in thecranial direction. This displacement favours contact

between the tear duct of the lower eyelid and the eyeballto 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 per-formed in any patients which could modify the resultsobtained when the anchoring system is used. Thus, wepresent a technique with good results using an isolatedprocedure.

Acknowlegements

We thank Mrs. Monica Mendigana and Mrs. Tatiana Acosta

for their help in the preparation of the manuscript.

References

1. Hontanilla B. Weight measurement of upper eyelid goldimplants for lagophthalmos in facial paralysis. Plast ReconstrSurg2001;108:1539e43.

2. Hontanilla B, AubaC. Surgical approach the correction of theparalysed eyelid in facial paralysis. Cir Pla st Iberlatinamer2004;30:275e84.

3. Warren AG. A method of medial tarsorraphy for correction oflagophtalmos and ectropion. Lepr Rev1966;37:217e8.

4. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateralcanthoplasty: techniques and indications. Plast Reconstr Surg1997;100:1396e405.

5. Frueh BR, Su CS. Medial tarsal suspension: a method ofelevating the medial lower eyelid.Ophthal Plast Reconstr Surg

2002;18:133e

7.6. Qian JG, Wang XJ, Wu Y. Severe cicatrical ectropion: repair

with a large advancement flap and autologous fascia sling. JPlast Reconstr Aesthet Surg2006;59:878e81.

7. Daigeler R, Bohmert H. Masseterplasty in facial paralysis. Useof the Gore-Tex (PTFE) soft tissue patch as a tendon rein.Fortschr Med1986;104:304e6.

8. Hontanilla B, Auba C. Automatic three-dimensional quantita-tive analysis for evaluation of facial movement. J PlastReconstr Aesthet Surg2008;61:18e30.

9. Hayashi A, Maruyama Y, Okada E, et al. Use of a suture anchorfor correction of ectropion in facial paralysis. Plast ReconstrSurg2005;115:234e9.

10. Terzis JK, Kyere SA. Minitendon graft transfer for suspension ofthe paralyzed lower eyelid: our experience. Plast Reconstr

Surg2008;121:1206e

16.

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 measuredwith the Facial Clima

Technique N Mean (mm) Std. Deviation

Screw anchors 17 0,2824 0,18109

Classical suspension 41 1,3585 0,41772

Table 2 Box-plot of distance between the inferior iris

border and the free border of the lower eyelid by using the

Facial Climasystem

Technique

Classical suspensionScrew anchores

Distance

mm

2,50

2,00

1,50

1,00

0,50

0,00

Surgical correction of lower eyelid 1601