UPPER LID REANIMATION PROCEDURES

The four procedures that I believe are the most useful in reanimating paralyzed lids are the following, in order of preference:

In all of these procedures, the principle is to create an external force that opposes the levator palpebrae superioris, the opening muscle of the lid. The respective forces are spring tension, gravity acting on the gold weight, and elasticity of the silicone rod.

The relative merits and limitations of the various procedures are related to how they develop external closing forces and the consequences of increasing those forces. The greater the force required by any device, the greater the pseudoptosis (lid droop in the primary position of gaze that results from the implant). If the palpebral spring, the gold weight, and the silicone rod prosthesis all are adjusted to provide the same closing force in a given patient, the pseudoptosis should be the same with each device. In the enhanced palpebral spring implantation procedure, the levator muscle is strengthened to balance the spring force, and less pseudoptosis is possible with the same closing force compared with any of the other three procedures. Similarly, by tightening the levator and using a stronger spring force, the surgeon makes increased blink speed possible.

Because the gold weight is gravity dependent, very large and unsightly gold weights may be required in lids that need a strong closing force. Also because the gold weight is gravity dependent, lid closure may not be guaranteed when the patient is supine, as in sleep. Blink speed is limited with the gold weight. Patients whose work or lifestyle requires their being in a very cold or hot environment may experience pain from the cold or hot gold weight in their eyelid. A surgeon who does these procedures only infrequently can more easily master the techniques of the gold weight implant and silicone rod prosthesis, however, than the technique of the palpebral spring implant or the enhanced palpebral spring implant.

The silicone rod prosthesis has the advantage of providing support for the lower lid as well. Its major disadvantage is its inevitable loss of elasticity over months or years. If facial nerve function does not recover before the prosthesis runs out of elasticity, it will need to be replaced. By contrast, a gold weight or palpebral spring can function over many years. A small percentage of springs may fail over time because of fatigue and breakage, necessitating replacement.

An additional advantage of the palpebral spring is that the tension on the wire can be adjusted postoperatively, either externally or through a small incision. This technique allows loosening of the spring when the patient recovers partial function, but is not yet well enough to have the spring removed.

All prosthetic devices are subject to the potential hazards of extrusion or infection over the long-term. With the techniques currently in use, these complications have been sufficiently infrequent, however, as not to limit the usefulness of the devices.

In recent years, since I devised the enhanced palpebral spring procedure, I have used it with increasing frequency instead of nonenhanced spring implantation. The extra surgical effort is usually well rewarded by the diminished pseudoptosis and increased blink speed obtained by this procedure. I prefer the enhanced palpebral spring implantation in most cases of significant upper lid closure deficits. When the patient has a strong levator or when the spring is being used only as a short-term remedy, the nonenhanced palpebral spring procedure may be used. Surgeons who are just beginning to undertake palpebral spring implantation should start off with the nonenhanced procedure and then move on to the enhanced procedure.

I find the gold weight beneficial to patients whose closure problem is minimal, but nevertheless just exceeds the limits of conservative management. Patients who require definitive, reliable closure, such as patients with coexistent poor Bell’s phenomenon or CN V involvement, are better protected with springs than with weights. Patients whose ocular management failed with weights in place have been successfully treated by removing the weights and replacing them with springs. The silicone elastomer (Silastic) elastic prosthesis is most useful in patients with an excellent prognosis for recovery in about 6 months in whom significant lower lid lagophthalmos coexists because stretching of the prosthesis over time may decrease its function after 6 months.

Palpebral Spring Implantation

The palpebral spring^4–14 is built preoperatively either in the office or at the bedside. Building the spring is time-consuming, and the surgeon and the patient should be comfortable during the procedure. Good light must be available, and if possible, the patient should be seated so that lid movement can be best evaluated.

Each spring is constructed from a plain piece of wire that is shaped to conform to the individual lid anatomy of the patient. Generally, a 0.011 inch wire provides suitable tension for most patients. Patients with very strong levators may require the use of 0.011 inch or 0.012 inch wire, and patients with weak levators (especially when the levator is not going to be tightened) may benefit from the use of 0.009 inch or 0.008 inch wire. A new wire used in pacemaker leads, the alloy 35NLT (Fort Wayne Metals), has been made with sufficient tensile strength to replace the previous alloy. With this wire, the 0.011 inch wire diameter often does need to be varied. Because of its track record in biomechanical applications, it is anticipated to have excellent longevity.

The construction is begun by forming an 8 mm loop at what is to become the fulcrum of the spring. The posterior aspect of that loop should be the superior arm of the spring. Because loosening the spring intraoperatively is easier than tightening it, the two arms should form an angle of about 120 degrees as they leave the fulcrum.

The fulcrum is placed over the lateral orbital rim and held in position by the surgeon’s fingers. Curves are created in the lower arm to match the patient’s lid anatomy. Curvature is also provided to accommodate the fact that the upper eyelid opens up and back, not straight up and down. Slight variations in spring position and curvatures may enhance its effect; these factors should be varied in the evaluation of the spring preoperatively.

Sometimes, making more than one spring with slightly different curvatures is useful in determining which model would work best. Usually, the fulcrum should be placed as far laterally as possible without lengthening the spring so much that its design and placement are difficult. The completed spring is stored until the day of surgery, when it is placed on a gauze pad to prevent loss and sterilized in a low-temperature chemical unit and not a steam autoclave, to subject the wire to less heat stress. Alternatively, the wire may be sterilized in gas sterilizer 24 hours or more before surgery, and retained in a sterile envelope.

Surgical Technique

The eye is protected with a scleral shell. An incision is made along the lid fold at the junction of the medial one third and lateral two thirds of the palpebral aperture and is carried across the orbital rim (Fig. 61-2). Dissection is carried superolaterally, in the plane between the septum and orbicularis, to expose the orbital rim. Dissection is carried downward at the medial aspect of the incision to expose the tarsus.

FIGURE 61-2 Palpebral spring implantation. A, With protective scleral shell in place, incision is made along the lateral two thirds of the lid crease and is carried across the orbital rim laterally. Dissection is carried downward at the medial end of the incision to expose tarsal plate. Dissection is also carried upward and laterally to expose orbital rim. B, A 22 gauge blunted spinal needle with the stilette in place is passed from the medial end of the dissection to emerge laterally in the plane between orbicularis and the tarsus. Passage should be carried out overlying the midtarsus, and needle is angulated slightly downward at its lateral extent. Exit of the needle tract should be close to lateral orbital rim periosteum. The lid is everted to confirm that needle has not inadvertently perforated the tarsus. The previously prepared wire spring, sterilized in low-temperature chemical sterilizer or gas sterilizer, is passed through the needle, and needle is withdrawn. C, Cross section of lid illustrates placement of needle over the midtarsus in the plane between tarsus and orbicularis. Wire spring should be resting on the epitarsal surface. D, Scleral shell is removed, and fulcrum of the spring is brought into the desired position along the orbital rim. The spring should be placed in a position in which its curves conform perfectly to the eyelid contour. (Inset: Fulcrum of spring is secured to lateral orbital rim periosteum with three 4-0 Mersilene sutures, and an extra bite of the periosteum is taken with each stitch.) Loops are fashioned at each end, and the spring is cut to size. Loops should be flat and tightly closed to leave no sharp edges. The medial loop is enveloped in 0.2 mm thick polyester (Dacron) patch material, to which it is secured by means of three 8-0 nylon sutures tied internally. Polyester patch is creased in Gelfoam press before surgery and is autoclaved with the other instruments. The folded polyester envelope is cut to size at surgery. The crease in the patch material should be directed downward so that the spring and patch together provide a smooth inferior surface. The loop at the end of the inferior arm is directed upward for the same reason. Suturing of the loop to the polyester is facilitated by resting the polyester on a retractor. E, The end of the spring with its polyester envelope is replaced into the lid between tarsus and orbicularis. In time, the end of the spring becomes fixed to tarsus by granulation tissue integrating into the polyester patch. Securing the patch to the tarsus directly with an additional running 8-0 nylon suture helps to provide fixation until connective tissue grows into the polyester. Tension on the spring is checked, with the patient in the upright and supine positions. The tension can be adjusted by grasping the upper end of the spring with forceps and changing its position. When the correct tension has been determined, the upper loop of the spring is secured to the orbital rim periosteum with a 4-0 Mersilene suture. An extra bite of the periosteum may be taken in the stitch before it is tied. When sutures are placed to secure either the fulcrum or the upper loop of the spring to the orbital rim periosteum, it is safer to sew in the direction away from the globe. Spring tension is checked again with the patient seated and supine. Additional adjustments can be made by bending the wire or repositioning the loop. When the adjustments are completed, two additional 4-0 Mersilene sutures are placed through the upper loop in a manner similar to that of the initial suture. Deeper tissues overlying the spring are closed with 5-0 plain gut suture to ensure that the spring and Mersilene sutures are well covered. Skin and muscle are closed with running 6-0 plain gut fast-absorbing suture. F, The end of the spring should be at the pupillary axis, with eyes in the primary position of gaze.

(From Tse D, Wright KW [eds]: Oculoplastic Surgery. Philadelphia, Lippincott, 1992.)

A blunted 22 gauge spinal needle is passed, beginning in the area of the exposed tarsus, 5 mm superior to the lid margin. The needle passes in the plane between the orbicularis and the tarsus to a point 2 mm above the lid margin at the lateral aspect of the lid. It continues until it emerges at the anterior aspect of the lateral orbital rim. The stylette is then removed. The undersurface of the lid is inspected to ensure that the needle has not inadvertently perforated the tarsus.

The end of the lower arm of the previously prepared palpebral spring is passed into the needle, and the needle and spring are withdrawn medially, bringing the spring into the lid. The scleral shell is removed, and the spring is positioned so that its previously determined curvature conforms to the lid anatomy. The upper arm of the spring is placed in position, and its length is determined. It usually needs to be about ¾ inch long. A loop is fashioned at the point that is to become the end of the upper arm, and the wire is cut to size. The loop is closed to leave no sharp ends. The upper loop is made at a 90 degree angle to the fulcrum loop so that the upper loop can be tucked under the superior orbital rim. The loop is primarily held in place by pushing against the bone, decreasing the role of the sutures and helping to prevent late slippage. The loop at the fulcrum is held in place with forceps, and the patient is asked to open and close the eye. The position at which the spring curvature best conforms to the lid anatomy is then found, with the eye opened and closed, and the loop at the fulcrum is sutured in place. The suturing is accomplished with 4-0 Mersilene suture, and an extra bite of periosteum is taken with each stitch. Three such sutures are generally placed for the nonenhanced procedure, and five are placed for the enhanced procedure because of the greater tensions involved.

The lower arm of the spring is cut to size, and a loop (which is also meticulously closed) is formed on its end. The loop should be formed upward to maintain a smooth inferior surface to the spring. The end of the spring should be at the pupillary axis, with the eyes in the primary position of gaze. Before the end of the spring is covered with polyester (Dacron) patch material, the angulation of the loop should be checked with the patient’s eyes open and closed to ensure that the spring tracks well with lid movement, and that the loop stays relatively parallel to the tarsus during opening and closing.

A piece of 0.2 mm polyester patch material, which has been creased by its placement in a press that is used for compressing absorbable gelatin sponge (Gelfoam) before it is autoclaved, is cut to size to fit over the inferior loop. This piece is converted into a pouch by closure of the sides with 8-0 nylon sutures tied internally. The creased side is directed downward. The open lateral side is slipped over the spring, to which it is secured with an 8-0 nylon suture beginning within the pouch. The suture is passed through the spring loop and the posterior end of the pouch and is terminated by passing through the anterior side of the pouch. The knot is tied internally to prevent erosion. The polyester envelope is secured to the tarsus with one or more 8-0 nylon sutures, as needed, to prevent slippage of the polyester until granulation to the tarsus occurs.

Spring tension is adjusted to just close the eye, by moving the upper arm of the spring closer or farther from the orbital rim. At the desired tension, the upper arm is bent so that the loop can be tucked under the orbital rim; it is secured with 4-0 Mersilene sutures to periosteum, taking an extra bite of periosteum with each stitch. Tension is checked with the patient seated and supine. Additional adjustments can be made by bending the wire of the upper arm to loosen or tighten it.

Bending the wire of the lower arm near the fulcrum should be avoided at this time because such adjustments may be required during the postoperative period, and excess bending of the wire may increase its chance of breakage. When the final position of the upper loop has been determined in the nonenhanced procedure, two additional 4-0 Mersilene sutures are placed, and an extra bite of periosteum is taken with each stitch. Four additional sutures are used in the enhanced procedure.

The deeper aspect of the wound overlying the orbital rim is closed with 5-0 plain gut suture to cover the spring and Mersilene sutures at the upper loop and fulcrum. The lid fold incision is closed with running 6-0 plain gut suture. The eye is dressed with antibiotic ointment and an ice pack.

Enhanced Palpebral Spring Implantation

The enhancement of the palpebral spring operation consists of tightening of the levator during the same procedure (Fig. 61-3). The spring is prepared similarly except that wire lighter than 0.010 inch is not used. I primarily use the 0.011 inch 35NLT (Fort Wayne Metals) alloy.

FIGURE 61-3 Enhanced palpebral spring implantation. A, Levator aponeurosis (LA) and inferior aspect of the muscular portion of the levator are exposed. Centrally, the superior portion of the tarsus is also exposed. A double-armed 5.0 Mersilene suture is placed through midtarsus. B, Each arm of the suture is brought superiorly through the levator to emerge just above the point at which the aponeurosis meets the levator muscle (LM). Temporary knots are tied. If necessary, an additional lateral suture and possibly an additional medial suture are placed in a similar manner. Inset: Course of suture is illustrated in cross section. The surgeon should check to ensure that the suture has not perforated tarsus or conjunctiva. PAF, preaponeurotic fat; S, orbital septum; STL, superior transverse ligament.

A scleral shell is placed. The initial skin fold incision is the same as that described earlier. Dissection is carried upward until preaponeurotic fat can be visualized through the septum. The septum is opened, and dissection is carried down to expose the levator. Dissection is carried inferiorly to expose the tarsus centrally. A 5-0 Mersilene suture is placed through midtarsus where the loop-polyester complex overlies the tarsus. The lid’s undersurface is inspected to be sure the suture has not perforated the tarsus. Both suture arms pass through the polyester, and the medial arm passes through the loop as well, before completing the suture through the levator, to emerge just above the point where aponeurosis ends and levator muscle is visualized. This serves the purposes of directly opposing the maximal force of the spring (at its distal end) with the levator force and of securing the polyester further until granulation tissue fixes it in place. A temporary knot is placed, and the patient is asked to open the eye.

The scleral shell is removed, and the extent of levator tightening is evaluated. If necessary, an additional lateral suture and possibly an additional medial suture are placed in a similar manner to achieve desired lid strengthening and maintenance of proper upper lid curvature. If the surgeon is unsure whether additional sutures are necessary, their placement can be deferred until after the spring has been placed, and the overall effect of the spring and the initial suture can be evaluated.

Regardless of how many sutures are used, they are adjusted after the spring is in place, at the same time that the spring itself would otherwise be adjusted. The levator is tightened to a point at which maximum strengthening is achieved without inducing cicatricial lagophthalmos from an overly shortened levator.

The stronger the levator can be made, the greater the tension possible on the spring, and the more rapid the blink. The nuances of adjustment of the levator and the spring can be appreciated only with experience. Nevertheless, when the general principles are understood, excellent results can be obtained (Fig. 61-4).

FIGURE 61-4 The patient is a 49-year-old woman with facial paralysis secondary to an acoustic neuroma. She had undergone two tarsorrhaphy procedures before she was first seen for evaluation. A, Eyes open, but eye function is largely blocked by tarsorrhaphy. Note also the brow droop. B, Attempted closure. Note that tarsorrhaphy, although extensive, fails to protect cornea well. C, Eyes open. Tarsorrhaphy has been opened, and lid margins have been reconstructed. The patient also has had enhanced palpebral spring implantation, medial and lateral canthoplasties, correction of upper lid entropion, and elevation of the brow. D, Attempted closure. Note excellent protection of the cornea by the spring.

FIGURE 61-5. Gold weight. The levator is exposed, and gold weight is secured to it with single 5-0 polyester suture placed through the holes in the weight. The knot is buried. Larger weights may be placed pretarsally in a similar manner. LA, levator aponeurosis; LM, levator muscle; T, tarsus.

Gold Weight Implantation

The size of the weight is selected preoperatively.^15,16 With the patient seated, a gold weight (or the comparable weight from a sizing set) that is estimated to be suitable for the degree of lagophthalmos is selected and is secured to the patient’s upper lid with cyanoacrylate glue, double-stick tape, or a temporary lid suture. The patient is asked to open and close the eye, and the surgeon determines whether the weight of the gold is correct. The evaluation is repeated with the patient supine. Weights of 1.2 to 1.5 g are suitable for use in most patients.

The weight may be fixated either supratarsally (Fig. 61-5) or tarsally. Supratarsal fixation is preferable unless the weight is so large that this is impractical. A scleral shell is placed. An incision is made in the lid fold, and dissection is carried upward to expose the orbital septum. The preaponeurotic fat can be seen through the septum, which is opened, and the weight is secured to the levator with a single 5-0 polyester suture placed through the holes in the weight. The knot is buried. The function of the weight is tested with the patient in the seated and supine positions. If the desired effect is not obtained, a different-sized weight may be tried. Overlying skin muscle is closed with running 6-0 plain gut suture.

FIGURE 61-6 Silicone rod prosthesis. A, Incision is made medially just lateral to angular vein; a second incision is made laterally over orbital rim. B, Laterally, dissection is carried down to expose orbital rim. Medially, the medial canthal tendon is exposed, and the prosthesis is sewn through it by use of a large noncutting needle. C, Prosthesis is sewn further through the tendon so that the lower arm emerges posterior to tendon, facilitating holding the lower lid against the globe. D, Each arm of the prosthesis is ready to be engaged on the introducer. E, With a special introducer, upper arm of the prosthesis has been passed between the orbicularis and tarsus in the upper lid, at the level of midtarsus. The introducer is shown in the lower lid, in preparation for passing the lower lid of the prosthesis. Prosthesis must be as close to lid margin as possible to prevent ectropion of the lid. F, Lower arm of prosthesis is secured to orbital rim periosteum with 2-0 Prolene suture. G, Both arms of prosthesis are sutured to the periosteum further with 2-0 Prolene. Inferior arm is posterior to superior arm because lower lid must be pulled posteriorly.

An alternative gold weight technique used by Michael Roberts MD, is presented.^17–19 It is based on 36 cases performed; no follow-up data are available.

The size of the weight is selected preoperatively. With the patient seated, a gold weight, or the comparable weight from a sizing set, is secured to the patient’s upper lid with cyanoacrylate glue, double-stick tape, or a temporary lid suture. Optimal position is 2 to 3 mm above the lash margin and centered horizontally within the lid where levator function is maximal. The patient is asked to open and close the eye, and the surgeon determines whether the weight of the gold is correct. Ideally, the paretic eyelid should close completely and remain equal to or 1 mm lower than the normal eyelid with both eyes open, as levator function improves in response to presence of the gold weight. The evaluation is repeated with the patient supine. Weights of 1 to 1.8 g are suitable for use in most patients. Similar weight sizes in platinum are also available for patients with a gold allergy. Special attention is needed for patients with proptotic eyes. In these patients, the globe partially supports the weight, and additional weight may be required for full lid closure.

Silicone Rod Prosthesis Implantation

The prosthesis to be used in silicone rod prosthesis implantation^20–22 is commercially available as a 1 mm diameter rod. While the eye is protected with a scleral shell, a curvilinear incision is made overlying the medial canthal tendon (Fig. 61-6). The incision should be just lateral to the angular vein to avoid the vein in the course of the dissection. Dissection is carried posteriorly to expose the origin of the tendon. The prosthesis is threaded on a large, noncutting needle (e.g., No. 5 Mayo needle), and is sewn through the tendon twice. The lower arm should emerge from the posterior aspect of the tendon, which facilitates holding the lower lid against the globe.

A second incision is made at the lateral orbital rim, and dissection is carried to the periosteum. By use of sharp dissection, a tunnel is started in the plane between the orbicularis and the tarsus at the lateral aspect of the lower lid. A special introducer is passed as close to the lid margin as possible across the lid to emerge medially close to where the silicone rod has been sewn through the tendon. The lower arm of the rod is threaded onto the introducer, and the introducer is withdrawn laterally, bringing the rod through the lid. In a similar manner, the upper arm of the prosthesis is brought through the upper lid except that passage is accomplished over the midtarsus.

The desired point of anchorage for the lower end of the prosthesis is determined, and a suture loop is formed at that point through periosteum by use of a 2-0 polypropylene (Prolene) suture sewn through the periosteum twice at the orbital rim. The prosthesis must be secured at the inner aspect of the lateral orbital rim to pull the lid posteriorly. The point selected should be just above the horizontal raphe to draw the lid upward as well. In a similar manner, the upper arm of the prosthesis is secured just below the horizontal raphe, passing anterior to the lower arm.

With the patient in the seated position, suitable tension is placed on the lower arm to secure the lower lid in the desired position. (For additional discussion on how to best position the lid, see the section on assessing lid position.) Similarly, the tension on the upper lid is adjusted to permit good opening and closing of the lid, and final knots are tied. Each arm of the prosthesis is secured further with additional suture bites through the lateral rim periosteum. A heavy suture, such as 2-0 Prolene, is selected to avoid cutting through the prosthesis. Deep tissues are closed with 5-0 plain gut suture medially and laterally, and the skin is closed with 6-0 plain gut suture.

Canthoplasty

Surgery may be performed at either the medial or the lateral canthus to tighten and elevate the lower eyelid. Operating at the ends of the tarsus has the advantage of not creating an irregular lid margin or interfering with the visual field. Although tightening the lid only at the lateral canthus is usually the procedure of choice in patients with nonparalytic lid laxity, the paralyzed lid usually requires medial canthal tightening as well. Otherwise, tightening the lid only laterally may result in either marked displacement of the inferior punctum laterally or failure to elevate the lid. In some cases, tightening the lid only laterally can cause the lid to act as a shorter chord beneath the globe—lowering the lid rather than raising it. If only a limited amount of lid tightening and elevation is required, medial canthoplasty alone may be the procedure of choice.

Assessing Lid Position

Assuming that extraocular motility has not been impaired by excess local anesthesia infiltration, the position of the lid relative to the limbus (corneoscleral junction) can be used as a guideline in the adjustment of lid position. The gaze of the patient should be directed such that the limbus of the contralateral lid is placed just tangential to the inferior limbus. The lid being operated on can be tightened to a position in which it, too, is tangential to the limbus, or it can be slightly overcorrected to allow for postoperative loosening. Matching this tangential position is more precise than judging the amount by which the lid crosses the cornea or comes inferior to it compared with the other eye.

Medial Canthoplasty

Medial canthoplasty²³ consists of exposing the lower arm of the medial canthal tendon and the origin of the common tendon and tightening the lower arm. If additional effect is required, the upper arm of the tendon may also be exposed so that it, too, can be included in the surgical procedure.

Surgical Technique

To expose the medial canthal tendon, the globe is protected with a scleral shell, and the canaliculi are protected with probes. An incision is made at the mucocutaneous junction, beginning 2 mm medial to the lower punctum, along the mucocutaneous junction to the medial canthus, and for an additional 2 mm beyond the canthus (Fig. 61-7). A skin/muscle flap is elevated with scissors, and hemostasis is achieved with bipolar cautery. The insertion of the lower arm of the medial canthal tendon is grasped with forceps and drawn superonasally, permitting the placement of a 5-0 double-armed polyester suture through the insertion. Each arm of the suture is woven through the tendon and sewn through the origin of the tendon. Temporary knots are tied.

FIGURE 61-7 Medial canthoplasty. A, While globe is protected with scleral shell, and canaliculi are protected with probes, an incision is made along the mucocutaneous junction and continued downward at a point 2 mm medial to the punctum. B, Inferior flap is elevated, which exposes inferior arm of medial canthal tendon. Tendon is pulled medially to expose its junction with lateral aspect of tarsus (insertion of the tendon), and a 5-0 polyester double-armed suture is placed through insertion. C, Each arm of the suture is woven through the tendon and brought through the origin of the tendon. The two sutures are tied under appropriate tension, tightening lower lid. Mucocutaneous junction is reconstructed with 8-0 Vicryl suture, leaving medial canthus with a normal appearance. D, If additional lower lid inversion is required, a second incision is made in upper lid along mucocutaneous junction, directed upward at a point 2 mm medial to punctum. E, Superior flap is elevated, which exposes superior arm of canthal tendon. F, A 5-0 polyester suture is placed as a horizontal mattress suture. The suture passes near the lower end of the lower tendon and near the upper end of the upper tendon, inverting the lids. G, Edges of the skin flaps are closed to each other with 6-0 plain gut suture. The steps shown in D-G may be performed independently when lid inversion is more important than lid tightening, or they may be combined with the steps shown in A-C. When steps D-G are required, the result is a more blunted medial canthal angle, with some shortening of horizontal fissure. If the procedure shown in A-C suffices, it is preferable. Nevertheless, the additional steps may be required in patients with marked medial lid laxity or eversion.

The patient is brought to the seated position, and the apposition of the lid and position of the punctum are evaluated. If a lateral canthoplasty is also being performed, sitting the patient up can be deferred, and tension on both sets of canthoplasty sutures can be adjusted simultaneously after completion of the lateral canthoplasty. If only a medial canthoplasty is being performed, the tension on the lid is adjusted, and final knots are tied. If the punctum is inadequately inverted by the suture used to tighten the medial canthal tendon, the canthal tendon is exposed in the upper lid, and a second 5-0 polyester suture is placed. Each arm of that suture starts at the lower edge of the inferior canthal tendon and ends at the upper edge of the superior canthal tendon, inverting the lower punctum further.

The canthoplasty using a suture only in the lower lid is completed by reforming the mucocutaneous junction with 6-0 plain gut (on a tiny needle) running or interrupted sutures. These sutures may be allowed to dissolve or may be removed in 5 to 7 days. When a second canthal suture is required, the lid flaps are closed to each other with 6-0 plain gut sutures. Because a second canthal suture results in the blunting of the canthal angle and horizontal shortening of the palpebral fissure, such a suture should not be used unnecessarily.

Lateral Canthoplasty

The object of lateral canthoplasty^24,25 is to pull the lid superoposteriorly against the globe. In lieu of the various lid-shortening procedures that have been used in the past, the currently preferred method is to create a new lateral canthal tendon from the tarsus itself, and to secure it to the orbital rim.

Surgical Technique

A hemostat is placed across the lateral canthal angle and removed (Fig. 61-8). The clamped area is cut with scissors, accomplishing a canthotomy. The inferior crux of the lateral canthal tendon is cut (inferior cantholysis) with scissors. At this point, the lateral aspect of the lower lid is freely movable. The lid is pulled taut across the globe. If a medial canthoplasty has been performed, suitable tension should be placed on that canthoplasty suture before this maneuver.

FIGURE 61-8 Lateral canthoplasty. A, Hemostat is used to clamp lateral canthal angle for hemostasis. B, Clamp is removed, and a lateral canthotomy is performed. C, Inferior canthal tendon is cut so that lower lid is freely movable. D, Lower lid is approximated to desired position with slight overcorrection. E, Excess skin muscle and mucocutaneous junction tissue are excised, leaving a tarsal tongue. F, Double-armed 5-0 polyester suture is passed through tarsal tongue, and one arm of the suture is marked with a marking pen for subsequent identification. A tunnel is created under the superior arm of the lateral canthal tendon. A clamp is passed into the tunnel, and the sutures are grasped and withdrawn laterally. The tarsal tongue is brought into the tunnel and secured under the desired tension to the lateral orbital rim periosteum. By use of identifying markings previously placed, superior suture is kept superior, and inferior suture is kept inferior, preventing twisting of the tarsus. Suture is tied under appropriate tension. Canthoplasty is completed with 5-0 plain gut suture to re-establish the canthal angle and 6-0 plain gut suture to close skin muscle. G, When lateral canthoplasty is combined with spring implantation, and only a moderate amount of lateral canthal tightening is required, the procedure can be accomplished through the prior lid fold incision. H, Tunnel is made under superior arm of the lateral canthal tendon. Forceps is introduced into the tunnel, and lateral aspect of the tarsus is grasped. I, Lateral end of tarsus is drawn into the tunnel, and a doubled-armed 5-0 polyester suture is used to secure it. J, Each arm of 5-0 polyester suture is secured through orbital rim periosteum under suitable tension. OR, orbital rim; ST, superior tendon; T, tarsus.

The amount of excess lid is marked, and the skin/muscle lamina is separated from the tarsus lateral to this mark. The lid margin in this area is also removed. Some surgeons prefer to remove the conjunctiva at this point, leaving a pure tarsal tongue. I have not found such removal necessary, and the tarsus may be damaged during such attempts. A double-armed 5-0 polyester suture is passed as a mattress suture beginning on the anterior surface of the tarsus, 3 mm from the lateral end, with each needle emerging through the cut end. A second pass of each suture arm is made, and each arm of the suture is locked. The lower arm of the suture is marked with a marking pen for future reference.

A tunnel is made underneath the upper arm of the lateral canthal tendon, and a clamp is passed into the tunnel. The sutures are grasped within the clamp and brought through the tunnel. The desired location of the lid is determined, and the sutures are placed appropriately, with care taken to obtain a bite of orbital rim periosteum at the inside aspect of the rim, slightly superior to the desired lid position. In this manner, the lid is drawn up and posteriorly. The previously placed mark on the suture helps to avoid confusion about the location of the inferior arm of the suture. A temporary knot is tied, and the patient is brought to the seated position. Adjustments in lid position and tension can be made, and final knots can be tied.

The surgeon completes the canthoplasty by trimming excess skin and muscle, re-establishing the canthal angle with a 5-0 plain gut suture, and closing the skin with 6-0 plain gut suture. In situations in which lateral canthoplasty is combined with palpebral spring implantation, and the amount of lid tightening required is not too great, a variant of the technique may be used. In such circumstances, a separate canthal incision is not required. The upper arm of the lateral canthal tendon may be approached from the existent extended lid fold incision.

A tunnel is made under the upper arm of the tendon. With forceps placed into the tunnel, the lateral aspect of the tarsus of the lower lid is grasped and brought into the tunnel. A 5-0 polyester double-armed suture is placed in the tarsus. This stitch is used to recreate the lateral canthal tendon in a manner similar to that described previously. If a great deal of lid tightening is required, however, it is impossible to omit the steps of canthotomy and inferior cantholysis, and still adequately mobilize the lid to achieve the desired position.

Fascia Lata Suspension of Lower Lid

In patients in whom medial and lateral canthoplasty together are inadequate to elevate the central portion of the lid, the lid may be supported by a fascia lata suspension. In this procedure, the fascia lata is anchored at each end of the lid and acts as a hammock to support the central lid. Either autologous or banked fascia lata can be used. The preserved fascia lata is more subject to resorption over time; the autologous fascia lata is more likely to give a reliable long-term result. When autologous fascia lata is used, it is obtained from the leg by a general surgeon while the lid is being prepared for its placement. Nevertheless, because of the morbidity from the leg incision, I currently prefer to use preserved fascia.

Surgical Technique

A strip of fascia inch wide and approximately 4 inches long is used. The technique for placing the fascia within the medial canthal tendon and in the lower lid is similar to the technique described in the section on the silicone rod prosthesis. The medial end of the fascia is anchored with a 5-0 polyester suture passed twice through the fascia and the medial canthal tendon (Fig. 61-9). The knot of the suture should be well buried to avoid later erosion.

FIGURE 61-9 Fascia lata suspension. This technique is analogous to that shown for placing the silicone rod prosthesis. Fascial strip is placed on a large needle and sewn through medial canthal tendon, emerging behind tendon. The end is locked with 5-0 polyester suture. With the special introducer, the fascia is brought laterally through the lid, where it is secured to orbital rim periosteum with 5-0 polyester suture in a manner similar to that described in the section on lateral canthoplasty. Excess fascia lata is secured to the periosteum further by continuation of the same sutures after initial knots are tied. These sutures encircle the fascia rather than perforate it, to avoid tearing it.

FIGURE 61-10. Brow elevation. A, If skin muscle excision is not planned, incision is made as close as possible to the brow over the area that needs to be suspended. Usually, this area consists of approximately the central two thirds of the brow. B, When skin muscle excision is planned, ellipse to be excised is marked, and skin incision is performed. C, Skin and muscle have been removed. D, Regardless of whether skin muscle excision is required, suspension sutures are placed in a similar manner. Dissection is carried superiorly to expose periosteum. Sutures of 4-0 Novafil are placed through periosteum, and through subcuticular tissue at the lower end of the wound. After these have been tied under appropriate tension, the brow is closed in layers.

FIGURE 61-11. Correction of upper lid entropion. Series of 6-0 Vicryl horizontal mattress sutures are placed between lower edge of levator aponeurosis (LA) and subcuticular tissue close to inferior edge of wound. Tightening these sutures under appropriate tension rotates lashes outward, and creates a pleasing lid fold. LM, levator muscle.

The lateral end of the tendon is secured to the inner aspect of the lateral orbital rim with 5-0 polyester suture in a manner similar to that described for lateral canthoplasty, and is adjusted in a similar way before final knots are tied. The suture should encircle the fascia, however, rather than go through it to avoid tearing it. When the fascia has been fixed in its position, additional bites through the periosteum and around the fascia are desirable to prevent slippage. Performing canthotomy and inferior cantholysis may be necessary to mobilize the lid adequately so that the fascial suspension holds it in the desired position.

Lid Stents

An alternative to supporting the central portion of the lower lid with a sling is to use a stent. In the past, auricular cartilage grafts (which did not have curvature that matched the curvature of the lid) and hard palate grafts (which created significant morbidity at the donor site) were used. Because of the limitations cited, they were not used extensively. More recently, the availability of alloplastic materials (e.g., porous high-density polyethylene [Medpor]) have made lid stents a much more viable possibility.

I have devised a new technique for placing such a stent in which it can be placed over a guide from a small lateral incision. I use it frequently in conjunction with enhanced palpebral spring implantation.

Midface Support

The constant drag of the weight of the paralyzed face on the lower lid can undo the most expert lower lid repair. To prevent this from happening, it is important to stabilize or elevate the midface when planning lower lid reconstruction. Many ways of supporting the midface are described in the plastic surgical literature, and these descriptions are beyond the scope of this chapter. Currently, I have devised a technique that uses an Endotine ribbon secured to the lateral orbital rim.

Brow Elevation

An eyebrow can be elevated²³ in the following ways:

The coronal forehead lift requires extensive dissection, does not give as much effect as a direct lift, and may be difficult to control to elevate only one brow. A direct approach to brow elevation is generally preferable in patients with facial paralysis. Skin/muscle excision alone is less effective in the paralyzed frontalis than in a normally innervated frontalis. I have found combining skin/muscle excision with brow suspension, and brow suspension alone to be two simple, useful brow-elevating procedures. Endoscopic brow elevation is more time-consuming, and may be harder to do in a patient who is undergoing multiple procedures. It is an excellent procedure, however. The surgical technique of endoscopic brow lift is beyond the scope of this chapter.

The choice of the procedure depends on several factors. First, is frontalis function expected to return? If so, it is best not to excise tissue, but only to suspend the brow. The second factor to consider is the effect of raising the brow without tissue excision. In some patients, this process induces a few brow wrinkles, which are welcome from an appearance standpoint in a previously abnormally smooth paralyzed area. In other patients, only a bulge of tissue is created by elevation of the brow without tissue excision. In such patients, skin/muscle excision can be performed.

Elevating the entire brow is not always necessary. The point of maximum brow elevation should be noted on the contralateral side. A line drawn downward through this point usually passes at or near the lateral canthus. The exact position of such an imaginary line should be noted, and a comparable line should be marked on the side to be operated. Some patients have a different brow configuration and require more medial elevation.

When the point of maximum brow elevation is determined and marked, the brow is raised at that point. How much of the brow must be elevated to obtain a desirable contour can then be seen. The extent of required brow elevation can also be judged by drawing a line tangential to the point of maximum brow elevation on the contralateral side. This line is drawn perpendicular to a vertical line bisecting the nose. Corresponding points on each brow are marked and measured relative to the horizontal reference line to determine the extent of brow elevation required at each point on the paralyzed side.

If it cannot be determined with certainty whether tissue excision would be required, the extent of the anticipated excision should be marked in advance of lid infiltration, so that the determination is not distorted by the swelling induced by the injection. The brow can be suspended without tissue excision. If the result is not pleasing, skin/muscle excision can be carried out.

The role of the ptotic brow in aiding lid closure should be assessed. If a paretic brow that is assisting closure is raised without simultaneously performing a procedure such as spring implantation to enhance lid closure, the result may be worsened lagophthalmos.

Surgical Technique

The area in which brow elevation, tissue excision, or both are required is marked as close to the superior extent of the brow as possible (Fig. 61-10), which helps conceal the resultant scar. The skin is incised perpendicular to the skin surface with a scalpel blade until muscle is reached. Blunt dissection is carried out at each site where a suspension suture is deemed necessary. The brow is elevated during the dissection so that the frontalis periosteum is encountered superior to the brow. A 4-0 Novafil suture on a very curved needle is passed through the periosteum, and then through the dermis at the lower aspect of the wound as a horizontal mattress suture. One to four such sutures may be required, depending on the contour of the brow. When all of the planned sutures have been placed, and temporary knots have been tied, the patient is brought to the seated position, and the brow contour is adjusted to match that on the contralateral side in the primary position of gaze.

The normally innervated, nonfixated brow moves downward on lid closure—the suspended brow is incapable of doing this. Care must be taken not to elevate the brow so much that a cicatricial lagophthalmos is induced. Especially in patients in whom lid skin is in short supply (e.g., in patients who have undergone a previous blepharoplasty), fully elevating the paretic brow may be impossible without adversely affecting lid closure. In such cases, it is better to place the brow slightly lower than the contralateral side, rather than induce lagophthalmos. Final knots are tied. If skin/muscle excision is required, it can be carried out. The Novafil sutures are rotated to bury the knots deeply.

The brow should be closed in layers to minimize the scar. Depending on the thickness of the tissue, one or two rows of deep 5-0 or 6-0 polyglactin 910 (Vicryl) sutures are placed before skin closure with interrupted 5-0 plain gut sutures and a Steri-Strip.

Two alternative ways of elevating the brow are available—internally suspending the brow with suture or with a special Endotine prosthesis designed for this purpose. Both are performed through a lid fold incision, and may be excellent choices when brow elevation is being combined with eyelid surgery. In the case of suspending the brow with suture, dissection is carried under the brow, from the lid fold incision to a point above where the brow is to be raised. One or more 4-0 Novofil sutures are placed in periosteum and continued into deep tissue below the brow to elevate and fixate the brow. In the case of the Endotine prosthesis designed to be used just above the orbital rim, similar principles apply. Dissection is carried from the lid fold incision to just above the superior orbital rim, at which point periosteum is incised and elevated. Adjacent tissue is dissected to allow the brow to be mobilized. A hole is drilled in the line of maximal brow elevation, 15 mm above the superior orbital rim. A special drill is provided to use with the prosthesis. A 3-0 Prolene suture is loaded in the prosthesis before prosthesis placement. This suture is used to secure further the overlying tissue to the prosthesis after the brow has been positioned.

Correction of Upper Lid Entropion

Correction of upper lid entropion is most easily carried out in combination with enhanced or nonenhanced spring implantation. This correction can be carried out as a separate procedure by opening the lid in the lid fold or, in combination with gold weight implantation, by extending the lid fold incision across the entire lid.

A series of 6-0 Vicryl sutures is placed across the lid (Fig. 61-11). Each of these sutures begins supratarsally, in the levator, and continues as a horizontal mattress suture through subcuticular tissue just inferior to the lower aspect of the skin incision. Tightening these sutures rotates the lid margin outward, correcting the entropion resulting from the facial paralysis or from the downward pressure from an implanted prosthetic device. Tension on the sutures is adjusted at the time of surgery to give a slight overcorrection. The sutures also create a pleasing lid fold.

Lid Suture Taped to Cheek

A lid suture can be placed easily at the conclusion of a neurotologic or head and neck procedure in which the function of CN V or VII is anticipated to be compromised postoperatively. The suture protects the eye during the immediate postoperative period without impairing the ability to check for pupillary or other neurologic signs involving the eye. If the patient subsequently requires temporary eye protection involving less than round-the-clock eye closure, the suture may be taped out of the way (to the forehead) during part of the day and used to close the eye at other times.

The eye is protected with a scleral shell. A 4-0 or 5-0 nonresorbable monofilament suture is passed through the skin and orbicularis, which have been pulled away from the tarsus with forceps (Fig. 61-12). The needle is passed parallel to the tarsus. The two arms of the suture are tied together with multiple knots to prevent slippage underneath the tape and are secured to the cheek with a strip of tape. The suture is brought upward and locked with a second piece of tape. A third strip locks the suture further and keeps it out of the way. When it is necessary to inspect the eye or to check for pupillary signs, all three pieces of tape can be lifted together with the suture away from the cheek and then replaced. By placing antibiotic ointment at the suture sites in the lid, one can usually maintain a suture in the lid for 2 to 3 weeks without undue lid induration.

FIGURE 61-12 Lid suture. A 4-0 or 5-0 nonresorbable monofilament suture is passed through skin and orbicularis muscle (OM), which have been pulled away from the tarsus (T) with forceps. The two arms of the suture are tied together with multiple knots to prevent slippage underneath the tape, and are secured to the cheek with a strip of tape. The suture is brought upward and locked with a second piece of tape.

FIGURE 61-13. Temporary tarsorrhaphy suture. A, Each arm of a double-armed nonresorbable monofilament suture is passed through skin and orbicularis of the central third of the upper lid, beginning 5 mm above lid margin and exiting at gray line of lid margin. B, Sutures continue to the gray line of the lower lid, exiting through orbicularis and skin 5 mm below the lid margin. Two arms of the suture are placed 1 cm apart. C, Cotton bolsters are placed between suture and skin before suture is tied. Suture is tied with a bow, and the ends are left long.

Temporary Tarsorrhaphy Suture

Temporary tarsorrhaphy suturing allows the lids to be kept securely closed over several weeks without damage to the lid margins from the creation of a true tarsorrhaphy. It also permits one to inspect the eye at intervals by untying the suture, inspecting the eye, and retying the suture without having to replace it. It is particularly useful when there is a significant lower lid laxity component to the exposure problem.

The eye is protected with a scleral shell. Each arm of a double-armed, monofilament, nonresorbable suture is passed through the skin and orbicularis of the central third of the upper lid, beginning 5 mm above the lid margin and exiting at the gray line of the lid margin (Fig. 61-13). The sutures continue into the gray line of the lower lid, exiting through the orbicularis and skin 5 mm below the lid margin. The two arms of the suture are placed 1 cm apart. Cotton bolsters are placed between the suture and skin before the suture is tied. The suture is tied like a shoelace, with a bow (leaving the ends of the suture long), to facilitate untying and retying in the future. The bow and ends of the suture are taped out of the way to the lid. Antibiotic ointment is applied to the suture sites twice daily, allowing the suture to be maintained for several weeks without undue induration of the lid.