Modified silicone sling assisted temporalis muscle transfer in the management of lagophthalmos

Cerclage sling technique using temporalis muscle fascia to manage paralytic lagophthalmos: A preliminary study

PURPOSE

Despite various existing surgical techniques, treatment of facial nerve palsy remains difficult. The purpose of this report is to present the cerclage sling technique using temporalis fascia to manage paralytic lagophthalmos.

METHODS

A series of six patients underwent a cerclage sling technique using temporalis muscle fascia to treat paralytic lagophthalmos. The technique is presented in detail. Symptoms, palpebral fissures, and lagophthalmos were assessed pre- and postoperatively. Data were submitted for statistical analysis.

RESULTS

After surgery, all patients achieved a reduction in clinical symptoms. The upper eyelids had lowered, and the inferior eyelids had elevated, reducing ocular exposure even if mild residual lagophthalmos was present.

CONCLUSION

Cerclage using the temporalis muscle fascia sling technique is a safe and effective procedure to treat facial nerve paralytic lagophthalmos. A reduction in ocular exposure and lagophthalmos provides improvement in clinical symptoms and eyelid function.

The effect of various muscle transfer procedures on eye closure and blinking in longstanding facial palsy patients

BACKGROUND

Facial palsy causes paralytic lagophthalmos, which remarkably deteriorates a patient's quality of life. In cases where denervation time is over 18-24 months (longstanding facial palsy), a free or pedicled muscle transfer is needed to replace the denervated orbicularis oculi muscle.

PURPOSE

The purpose of this systematic review is to investigate the effect of various eye sphincter substitution procedures (free or pedicled muscle transfers) in longstanding facial palsy patients on eye closure and blink.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a systematic review of the Embase, Medline, Web of Science and Cochrane Library databases and Google Scholar. Our literature search yielded 4322 articles. Following a full-text review, 4 retrospective cohort studies and 21 case series were selected for this review. Meta-analyses using R package meta (version 6.5-0) were conducted.

MAIN FINDINGS

All free and pedicled muscle transfers in this review showed an improvement in the scores and measurements on eye closure and blink. The pedicled temporalis muscle transfer was the procedure most commonly performed as eye reanimation surgery and showed consistent good results. Using the random effects model, the pooled effect of mean difference in lagophthalmos after gentle eye closure post-operatively versus pre-operatively (mm) in patients who received a pedicled (temporalis) muscle transfer was -6.19 (I2 = 85%, 95% CI: -7.89; -4.49) whereas it was -4.11 (I2 = 85%, 95% CI: -7.26; -0.95) for free (gracilis or platysma) muscle transfers. The pooled proportion of patients with complete eye closure after surgery was 0.69 (I2 = 49%, 95% CI: 0.54; 0.82) in patients who received a pedicled (temporalis) muscle transfer and 0.40 (I2 = 74%, 95% CI: 0.13; 0.74) in patients who received a free (platysma) muscle transfer.

CONCLUSIONS

Unlike smile reanimation, dynamic eye closure and blink restoration are rather neglected topics in facial reanimation. The pedicled temporalis muscle transfer is often recommended as the first treatment of choice for eye reanimation in longstanding facial palsy patients since it is a reliable, straightforward procedure, that does not require complex microsurgery. However, with the advancements in the field of microsurgery, free muscle transfers are promising therapies, which may regenerate voluntary and spontaneous blinking.

Facial Nerve Trauma: Clinical Evaluation and Management Strategies

The field of facial paralysis requires the reconstructive surgeon to apply a wide spectrum of reconstructive and aesthetic principles, using a comprehensive array of surgical tools, including microsurgery, peripheral nerve surgery, and aesthetic facial surgery on the road to optimize patient outcomes. The distinct deficits created by different anatomical levels of facial nerve injury require a fundamental understanding of facial nerve anatomy. Palsy duration, followed by location and mechanism, will determine mimetic muscle salvageability, by means of either direct repair, grafting, or nerve transfers, whereas longer palsy durations will necessitate introducing a new neuromuscular unit, whether by muscle transfer or free functional muscle transplant. A thorough history, physical examination, and basic understanding of ancillary studies, emphasizing palsy duration, location, and mechanism of injury, are critical in evaluation, prognostication, and treatment strategies in traumatic facial palsy patients. The importance of ancillary and aesthetic procedures cannot be overstated. Although these do not provide motion, they constitute essential tools in the treatment of facial paralysis, providing both protective and improved aesthetic outcomes, yielding the highest impact in final surgeon and patient satisfaction, bringing our patients to smile not only on the outside, but also on the inside.