COCLIA

10/6/08

`Welcome to the beginning of the academic year.’-Samir Undavia, MD  

Eyelid Reconstruction

Layers of the Eyelid

Layers of the eyelid

• Anterior lamella– Skin– Orbicularis muscle

• Posterior lamella– Eyelid retractor– Tarsus– Conjunctiva

Layers of the eyelid- other contents

• Upper lid– Orbicularis oculi– Levator palpebrae

superioris– Muller's muscle– Sweat glands– Meibomian glands– Wolfring's glands– Tarsal plate

• Lower lid– Tarsal plate– Lower lid retractors– Orbicularis oculi– Sweat glands– Meibomian glands– Wolfring's glands

Eyelid repair

• Full-thickness laceration: 3-layer closure– Conjunctiva: plain gut (avoids conjunctival

irritaion), 6-0 or 7-0– Tarsal plate: fine absorbable suture (i.e. Vicryl)– Skin: fine monofilament suture (6-0 prolene or

nylon). Remove after 3-4d

Entropion

Entropion- Types• Congenital

– Extremely rare, usually lower lid

– Hypertrophy of pretarsal orbicularis

– Deficiency/absence of tarsal plate

• Involutional

– Loss of orbital volume; enopthalmos

– Upward migration of preseptal orbicularis

– Thinning of tarsal plate

• Cicatricial

– Scarring of palpebral conjunctiva

• Acute spastic

– Ocular irritation; infectious, inflammatory

Entropion repair• Medical- (for acute spastic) ocular lubrication, ABX, steroids, botox

of orbicularis oculi m.

• Surgical

– Snellen procedure- everting suture correction

– Horizontal tightening

– Weis procedure- full thickness horizontal lid incision

– Quickert procedure (combination of above)

– Inferior retractor plication

– Wedge excision of tarsal plate

Entropion repair

Inferior retractor plication

Ectropion• Abnormal eversion of the lid margin away from the globe; puts eye at

risk for corneal exposure, tearing, keratinization of the palpebral conjunctiva, visual loss.

• Types

– Congenital

– Involutional

– Cicatricial (scarring of anterior lamella)

– Paralytic (Bell's palsy)

– Mechanical (neurofibroma)

Ectropion

Congenital bilateral ectropion

Repair of ectropion• Initial therapy with lubrication, tape closure, squinting exersizes;

digital massage and steroids in cicatricial ectropion

• Surgical therapy- depends upon etiology– Horizontal lid laxity-lid shortening procedure– Cicatricial ectropion- excision of scar and augmentation of

anterior lamella with postauricular or upper lid skin graft– Medial ectropion- excision of medial conjunctiva and retractors

Canalicular injuries

Nasolacrimal system

Canalicular injury repair• Dilate punctum

• Identify medial cut end of canalicular system (loupes/microscope usually needed)

• Place silicone stent through punctum, through cut end, and retrieve in nasal cavity

• Reapproximate laceration with fine (7 or 8-0) vicryl suture

Dacryocystorhinostomy

• Used to bypass blockage of NLD via fistualization of lacrimal sac into inferior meatus of nasal cavity.

• Epiphora is most common indication• Can be performed externally; usually done

endoscopically now

Endoscopic DCR• Steps:

– Probe (lighted if necessary) inserted into upper or lower punctum, then viewed endoscopically

– Anterior portion of middle turbinate used as landmark – Elevate mucosal flap to expose lacrimal fossa– Drill out frontal process of maxillary bone and lacrimal bone to

expose lacrimal sac– Probe placed in sac to tent out– Sac incised in order to create neo-ostium so tears can drain

directly from canaliculus into nose through middle turbinate– Keep open with Crawford tube stent for 6 weeks to months

Endoscopic DCR

Blepharospasm

• Idiopathic, progressive, involuntary spasm of orbicularis oculi and upper face (corrugators and procerus mm.). Spasm may extend to lower face

• May render patient functionally blind• May be central in origin; mechanism unclear• Mangement-

– selective destruction of peripheral innervation (identify branches, confirm with n. stimulator, resect)

– Botox– Periorbital myotomy

FT lac of eyelid margin

• Principles– Reconstuct in layers for normal function; both

lamellae must be reconstructed– One lamella must be well-vascularized in order to

support the other (i.e. One flap/one graft, or two flaps; can't do two grafts--> leads to necrosis)

Repair of lid margin defects

• Principles: – Can repair up to 25% of lid margin in younger

person with primary closure (40% in older person with increasing lid laxity)

– <30%: direct closure with lateral cantholysis– <50%: lateral rotational flap (Tenzel)– >50%: different pedicled flaps (Kollner; Cutler-

Beard)

Primary repair

• Prepare tarsal edges by preparing vertically oriented ends for direct approximation

• Approximate lid margin first

• Then, close tarsus with fine absorbable suture

• Close skin and conjunctiva with silk (nylon?), plain gut

Tenzel flap

Cutler-Beard Flap

Lower eyelid defect reconstruction

Facial reanimation

Facial reanimation

• Unilateral facial paralysis can be devastating– Nerve injury, even slight, from otologic/

parotid/plastic procedures may not attain full function

– Surgical patients MUST understand risks of injury; but difficult to convey

• Goals: – Resoration of facial symmetry– +/- Restoration of motion

Facial nerve anatomy

Microscopic nerve anatomy

Sunderland Classification

Reconstructive modalities

• Considerations: – First, availability of viable proximal facial nerve?– Tumor ablation with nerve sacrifice: immediate

reconstruction with cable graft– If questionable viability (i.e., after CPA surgery),

wait 9-12 months– Static procedure if no viable reinnervation available;

may also be combined with dynamic procedure for immediate function

Order of preference

1) Spontaneous generation (observation)2) Facial nerve neurorraphy3) Facial nerve cable graft4) Nerve transposition5) Muscle transposition6) Microneurovascular transfer7) Static procedure

Management of the eye

• Failure to recognize eyelid dysfunction early results in entirely preventable ocular complications – exposure keratitis– corneal ulceration– blindness

• Initial management– Moisturization (artificial tears, ointments)– Exposure prevention (taping, occlusive dressing)– Education

Surgical procedures

• Lower lid (ectropion)– Tarsorraphy

• Simple• Lid-adhesion

– Wedge Resection– Canthoplasty

• Upper lid (lagophthalmos)– Gold weight– Palpebral springs– Silastic slings

Bell's phenomenon• Idiopathic facial paralysis

• 15-40/100,000

• Most common form of facial palsy

• Generally a dx of exclusion, but a positive one if:– unilateral paresis of all facial muscle groups– sudden onset– absence of ear/CNS disease

• Etiology unclear (ischemic vs. viral vs. entrapment neuropathy); likely inflammation within constrained bony canal leading to ischemia

• Treatment extremely controversial; steroids likely improve outcome

• Prognosis– Incomplete paralysis: excellent recovery– Complete paralysis:

• 71% complete recovery• 13% mild residual palsy• 16% fair-poor recovery

Facial nerve grafting

• Settings– Radical parotidectomy with nerve sacrifice– Temporal bone resection– Traumatic avulsion– CPA tumor resection

• Donor nerves– Greater auricular (opposite neck)– Sural – Medial antebranchial cutaneous

Nerve grafting

• Technique– Transection of graft and stumps with sterile razor– Anastomosis with four 9-0 or 10-0 nylon through

epineurium only– Tension free is critical! Need 8-10 mm of extra

length for each anastamosis (“lazy S” configuration)– Healthiest possible bed of supporting tissue

Nerve transposition

• Used when proximal facial n. stump unavailable– Hypoglossal

• Best option due to close proximity, less donor disability, similar brainstem control and reflex response

• Pure vs. jump graft• Disadvantages: tongue atrophy, synkinesis, facial

hypertonia– Spinal accessory– Ansa hypoglossi plus muscle block– Phrenic (obsolete)

Muscle transfer

• Used when first two options unavailable, or when significant muscle atrophy has occurred (i.e., complete paralysis for two years or more)

• Masseteric transfer – Used for sagging/paralyzed oral commissure– Requires intact CN V– Provides posterior pull on midface– Cannot be used for orbital rehabilitation

• Temporalis transfer– Muscle divided into four slips– Superior pull preferred to masseteric vector

Static procedures

• Indications– debilitated patients with poor prognosis– Lack of nerve/muscle availability– Adjunct to dynamic procedure

• Advantages– immediate restoration of symmetry– Improvement in oral competence, nasal obstruction

• Materials– Fascia lata– Alloderm– PTFE

Harii et al. One-Stage Transfer of the Latissimus Dorsi Muscle for Reanimation of a Paralyzed Face: A New Alternative.

• One-stage microvascular free transfer of the latissimus dorsi muscle for long-standing unilateral facial n. paralysis

• Thoracodorsal nerve is crossed through the upper lip and sutured to the contralateral intact facial nerve branches.

• Reinnervation of the transferred muscle is established at a mean of 7 months postoperatively, which is faster than that of the two-stage method.

• 24 patients, 21 patients (more than 87 percent) believed that their results were excellent or satisfactory, which also compares well with the results of the two-stage method combining free-muscle transfer with cross-face nerve graft.

Cronin et al. The effectiveness of neuromuscular facial retraining combined

with electromyography in facial paralysis rehabilitation Objective

The study goal was to present the effectiveness of neuromuscular facial retraining techniques used in combination with electromyography forimproving facial function even in cases of longstanding paralysis.

Study design and setting

We conducted a retrospective case review in a tertiary neurotology clinic.

Patients

Twenty-four patients with facial paralysis received neuromuscular facial retraining between April 1999 and April 2001. The patient sample included 6 males and 18 females, with an average age of 44 years. A control group consisted of 6 patients (4 females and 2 males).

Results

All patient groups made significant improvements in function with improved symmetry in dual-channel electromyographic readings and increased facial movement percentages. Some of the percentages of posttreatment facial function were as follows: acoustic neuromas, 93%; Bell’s palsy/Ramsay Hunt syndrome, 80%; and facial nerve anastomosis, 71%. Synkinesis was reduced by at least 2 levels in patients who initially demonstrated synkinesis.

Conclusions

Neuromuscular facial retraining exercises and electromyography are effective for improving facial movements.