Upper Eyelid Gold Weight Implantation in the Asian Patient with Facial Paralysis

Transcription

1 Upper Eyelid Gold Weight Implantation in the Asian Patient with Facial Paralysis Phillip H. Choo, M.D., Susan R. Carter, M.D., and Stuart R. Seiff, M.D. Sacramento and San Francisco, Calif. Patients with facial paralysis may develop ophthalmic complications. Poor eyelid closure and lagophthalmos place the patient at increased risk for the development of corneal problems such as epithelial defects, stromal thinning, bacterial infection, and even perforation. Initial treatment should be conservative and include the use of ocular lubricants, moisture chambers, and taping of the lower eyelid into proper position. Surgical intervention may be required in patients who have failed medical therapy or in whom the facial paralysis is not expected to improve. Gold weight implantation in the upper eyelid has become a popular procedure to correct upper eyelid retraction and to improve corneal coverage. Previous descriptions of gold weight placement in the upper eyelid have focused on Caucasian eyelid anatomy. However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which dictate the overlying aesthetic differences. We describe our technique for placement of a gold weight in the Asian upper lid, with attention to the maintenance of symmetric eyelid creases. We reviewed the charts of six Asian patients with facial paralysis who underwent gold weight placement in the upper eyelid for the correction of lid retraction. All patients did well functionally and aesthetically, and none developed an extrusion of the implant with this approach. (Plast. Reconstr. Surg. 105: 855, 2000.) Patients with facial paralysis can have numerous ophthalmic manifestations including upper eyelid retraction, lower eyelid ectropion, poor eyelid closure or lagophthalmos, and decreased tear production. Patients with these findings are at increased risk for developing complications secondary to corneal exposure, such as epithelial defects, stromal thinning, bacterial infection, and perforation. Initial treatment includes the use of ocular lubricants, moisture chambers, and taping of the lower eyelid into proper position. 1,2 However, some patients continue to have signs of corneal exposure even on maximal medical therapy. Others are stable on maximal medical therapy, but the facial paralysis fails to improve, and they are subsequently faced with the tedious work of continually lubricating the exposed cornea. These two categories of patients are candidates for surgical correction of lagophthalmos. 2 Gold weight implantation in the upper eyelid is an effective procedure to correct upper eyelid retraction in patients with facial paralysis and corneal compromise. 3 5 Previous descriptions of gold weight placement in the upper eyelid have focused on Caucasian eyelid anatomy. 6 However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which are responsible for the overlying aesthetic differences. 7 9 Inferior descent of the brow fat pad or submuscular fibroadipose layer in the Asian eyelid, in combination with a low insertion point for the orbital septum, results in a low or indistinct eyelid crease and a fullappearing eyelid To maintain symmetry and the natural Asian appearance, these anatomic differences must be considered when a gold weight is implanted into an Asian upper eyelid. We describe our technique and review the results of Asian patients who have undergone this procedure. METHODS Preoperative Assessment The presence or absence of a crease is noted in both upper eyelids, and the height of the crease from the eyelid margin is measured. From the Ophthalmic Plastic and Reconstructive Surgery Service, Department of Ophthalmology at the University of California Davis, and the Division of Ophthalmic Plastic and Reconstructive Surgery at the Beckman Vision Center and Department of Ophthalmology, University of California San Francisco. Received for publication April 26, 1999; revised July 22, None of the above authors has any commercial association with the MedDev Corporation. 855

2 856 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2000 The proper size gold weight is then selected for implantation by taping a progressively larger weight onto the skin of the retracted upper eyelid until lagophthalmos resolves. However, the weight should not be so heavy that it creates a significant ptosis. If further corneal coverage is necessary, a lower eyelid tightening procedure may be necessary at the same time as the gold weight placement. Surgical Procedure A preexisting eyelid crease is marked with a fine-tip marking pen just slightly wider than the width of the gold weight chosen for implantation. If no crease is present in either of the upper eyelids, an incision approximately 3 to 4 mm from the upper eyelid margin is marked. The medial extent of the incision should not extend past the superior punctum or into an epicanthal fold because of the risk for medial canthal webbing. An additional mark is placed at the margin in line with the center of the pupil in primary gaze. The upper eyelid is then injected with anesthetic solution, and the surgical field is prepared and draped under sterile conditions. A 4-0 silk traction suture is placed through the upper eyelid margin to retract the lid inferiorly. An incision through skin and pretarsal orbicularis oculi muscle is made. Dissection is carried down to the anterior surface of the tarsal plate. If either the submuscular fibroadipose layer or the preaponeurotic fat pads are encountered, care should be taken not to excise these structures. Instead, they should be retracted away from the field with a Desmarres retractor to increase visualization. Once dissection has been made to the anterior surface of the tarsal plate, a pocket to house the gold weight is made anterior to both the levator fibers and the tarsal plate. The pocket should be somewhat larger than the actual size of the gold weight and displaced slightly medial to the center of the pupil in primary position (Fig. 1, above). During the dissection and creation of the pocket, the attachments of the levator aponeurosis to the anterior surface of the tarsal plate should not be disinserted. Although a limited levator recession may be helpful in correcting the upper eyelid retraction, one may cause an iatrogenic ptosis. In addition, if facial nerve function improves and the weight is removed, the patient may be left with a residual ptosis. Instead, the gold weight should be placed anterior to the FIG. 1.(Above) Dissection has been made to the anterior surface of the tarsal plate, and a pocket for the gold weight has been created. Note the low crease incision and the preservation of the submuscular fibroadipose layer. (Center) Gold weight is secured in place with sutures placed through the positioning holes and into partial-thickness tarsal plate. The fibroadipose layer is then brought over the implant before closure. (Below) Immediate postoperative appearance of the right upper eyelid. fibers of the levator aponeurosis as well as the tarsal plate (see Fig. 3). Interrupted sutures are then placed through each of the three positioning holes of the gold weight and attached to the tarsal plate with partial-thickness bites. The eyelid must be everted and checked for full-thickness suture

3 Vol. 105, No. 3 / UPPER EYELID GOLD WEIGHT IMPLANTATION 857 passes. Full-thickness passes may lead to corneal abrasions or ulcers, which are extremely difficult to treat in facial palsy patients. The three sutures are then tied sequentially, applying only light pressure. This prevents buckling of the tarsal plate if there is uneven placement of the sutures in relation to the positioning holes. Once the gold weight is secured in place, the preaponeurotic fat pads and the submuscular fibroadipose layer are brought over the gold weight (Fig. 1, center). The orbicularis muscle layer and skin are then closed as separate layers (Fig. 1, below). RESULTS The charts of six Asian patients with facial paralysis who underwent placement of a gold upper eyelid weight (MedDev, Palo Alto, Calif.) were reviewed (Fig. 2). Four women and two men, ranging in age from 38 to 82, had unilateral facial palsies and corneal exposure. Etiology of the facial palsy was idiopathic in two patients and occurred following intracranial FIG. 2.(Above) Same patient 3 months after gold weight implantation in the right upper eyelid. Note the preservation of the single upper eyelid crease and the epicanthal fold to maintain the Asian appearance of this patient. (Below) Same patient on attempted eyelid closure. tumor resection in four patients. The range of gold weights used was 1.2 to 1.6 g. Follow-up ranged from 12 to 60 months, with a mean of 26.5 months. All patients experienced an improvement in corneal epithelial defects and lagophthalmos after placement of the gold weight. Infection, inflammation, migration, and extrusion were not observed in any of the patients. DISCUSSION The Asian upper eyelid crease has received much attention in the plastic surgery literature This interest has been promoted by the popularity of the Asian blepharoplasty or double eyelid surgery. In the past, some authors have focused on achieving a westernized or Caucasian appearance. 26,27 In our experience, most of the Asian patients whom we have consulted for an upper blepharoplasty have wanted to maintain their Asian appearance. The difference between the Asian and the Caucasian upper eyelid crease is dictated by the difference in the underlying anatomy. The upper eyelid crease forms at the highest point of attachment of the levator aponeurosis to the subcutaneous tissue. In Caucasians, the orbital septum inserts onto the anterior surface of the levator aponeurosis above the superior border of the tarsal plate and holds the preaponeurotic fat pads in place. This allows the anterior fibers of the levator aponeurosis to extend to the subcutaneous tissue at or above the superior border of the tarsal plate and to create a high upper eyelid crease. In Asians, the brow fat often descends inferiorly as the submuscular fibroadipose layer (Fig. 3). This layer provides fullness to the upper eyelid, acts as a barrier between the anterior fibers of the levator aponeurosis and the subcutaneous tissue, and prevents the formation of a high eyelid crease. Furthermore, in Asians the insertion site of the orbital septum onto the anterior surface of the levator aponeurosis is variable. In this area, the septum becomes diffuse and less prominent, allowing for the inferior descent of the preaponeurotic fat pads. It is this combination of a prominent submuscular fibroadipose layer, weak inferior septum, and the inferior descent of the preaponeurotic fat pads that can either prevent the formation of an eyelid crease (single eyelid) or create a low crease (double eyelid). These anatomic differences need to be con-

4 858 PLASTIC AND RECONSTRUCTIVE SURGERY, March 2000 FIG. 3. This diagram illustrates some of the differences between the Caucasian and Asian upper eyelids. Both the preaponeurotic fat pads (P) and the fibroadipose layer (F) descend more inferiorly in the Asian upper eyelid. The white arrows point to recommended incision sites for gold weight implantation. Notice that the incision should be made lower in the Asian eyelid. In addition, the gold weight (white rectangle) may be placed slightly lower on the tarsal plate in the Asian eyelid. In both cases, however, the gold weight is placed anterior to both the tarsal plate and the inferior fibers of the levator aponeurosis, which insert onto the surface of the tarsal plate. sidered when planning gold weight placement in the Asian patient. One should focus on maintaining symmetry with the unaffected side and take special steps during the procedure to maintain a low or single eyelid crease. First, one should avoid a high incision (generally 8 to 10 mm from the lash margin in the Caucasian eyelid), which may promote a bifid or a westernized crease. Instead, the incision should be kept low (3 to 4 mm from the lash margin) or at a preexisting crease if present (Fig. 3). Furthermore, one may encounter brow fat (submuscular fibroadipose layer) as well as the preaponeurotic fat pads during dissection toward the anterior surface of the tarsal plate. If this occurs, the brow fat and the preaponeurotic fat pads should be preserved. These layers act as a barrier between the anterior fibers of the levator aponeurosis and the overlying dermis and prevent the formation of an unwanted eyelid crease above the incision. In addition, these layers help to prevent an anterior extrusion of the gold weight implant and counteract upper eyelid retraction by providing an extra weight load. Another difference in technique between the Asian and Caucasian eyelids is the location of the gold weight implantation. In Caucasian eyelids, some surgeons prefer to place the gold weight high in the lid to reduce visibility of the weight. However, the weight in the Asian eyelid can be placed lower because it is camouflaged by both the preaponeurotic fat pads and the fibroadipose layer (Fig. 3). One criticism of the above technique may be the low incision. Catalano et al. 28 stated the importance of not overlapping any portion of the implant to prevent an extrusion. In our series, none of the patients has developed an extrusion. However, this is a serious concern, and we try to prevent this by covering part if not all of the implant with the submuscular fibroadipose layer and the preaponeurotic fat pads. Next, we advocate meticulous closure of

5 Vol. 105, No. 3 / UPPER EYELID GOLD WEIGHT IMPLANTATION 859 the orbicularis muscle and the overlying skin in two separate layers. In conclusion, with careful attention to the anatomic differences between Asian and Caucasian eyelid anatomy, one can implant a gold weight in the Asian upper eyelid to improve function while preserving the natural appearance of the Asian patient. Phillip H. Choo, M.D. University of California Davis Medical Center Department of Ophthalmology 4860 Y. Street, Suite 2400 Sacramento, Calif phchoo.@ucdavis.edu ACKNOWLEDGMENT This work was funded in part by the Research to Prevent Blindness Foundation. REFERENCES 1. Seiff, S. R., and Carter, S. R. Reanimation of the paretic eyelid complex. Facial Plast. Surg. Clin. North Am. 6: 21, Seiff, S. R., and Chang, J. S., Jr. The staged management of ophthalmic complications of facial nerve palsy. Ophthalmic Plast. Reconstr. Surg. 9: 241, Chapman, P., and Lamberty, B. G. H. Results of upper lid loading in the treatment of lagophthalmos caused by facial palsy. Br. J. Plast. Surg. 41: 369, Pickford, M. A., Scamp, T., and Harrison, D. H. Morbidity after gold weight insertion into the upper eyelid in facial palsy. Br. J. Plast. Surg. 45: 460, O Connell, J. E., and Robin, P. E. Eyelid gold weights in the management of facial palsy. J. Laryngol. Otol. 105: 471, Seiff, S. R., Sullivan, J. H., Freeman, L. N., and Ahn, J. Pretarsal fixation of gold weights in facial nerve palsy. Ophthalmic Plast. Reconstr. Surg. 5: 104, Seiff, S. R. Anatomy of the Asian eyelid. Facial Plast. Surg. Clin. North Am. 4: 1, Liu, D., and Hsu, W. M. Oriental eyelids: Anatomic difference and surgical consideration. Ophthalmic Plast. Reconstr. Surg. 2: 59, Carter, S. R., Seiff, S. R., Grant, P. E., et al. The Asian lower eyelid: A comparative anatomic study using high-resolution magnetic resonance imaging. Ophthalmic Plast. Reconstr. Surg. 14: 227, Hisatomi, C., and Fujin, T. Anatomic considerations concerning blepharoplasty in the Oriental patient. Adv. Ophthalmic Plast. Reconstr. Surg. 2: 151, Doxanas, M. T., and Anderson, R. L. Oriental eyelids: An anatomic study. Arch. Ophthalmol. 102: 1232, Kim, M. K., Rathbun, J. E., Aguilar, G. L., and Seiff, S. R. Ptosis surgery in the Asian eyelid. Ophthalmic Plast. Reconstr. Surg. 5: 118, Sayoc, B. T. Plastic construction of the superior palpebral fold. Am. J. Ophthalmol. 38: 556, Pang, H. G. Surgical formation of upper lid fold. Arch. Ophthalmol. 65: 783, Boo-Chai, K. Plastic construction of the superior palpebral fold. Plast. Reconstr. Surg. 31: 74, Sayoc, B. T. Anatomic consideration in the plastic reconstruction of a palpebral fold in the full upper eyelid. Am. J. Ophthalmol. 63: 155, Rubenzik, R. Surgical revision of the Oriental lid. Ann. Ophthalmol. 9: 1189, Zubiri, J. S. Correction of the Oriental eyelid. Clin. Plast. Surg. 8: 725, Doxanas, M. T., and Serra, F. Surgical revision of Oriental eyelids. Ophthalmic Surg. 16: 657, Chen, W. P. Asian blepharoplasty: Update on anatomy and techniques. Ophthalmic Plast. Reconstr. Surg. 3: 135, Weng, C. J., and Noordhoff, M. S. Complications of Oriental blepharoplasty. Plast. Reconstr. Surg. 83: 622, Fernandez, L. R. The East Asian eyelid: Open technique. Clin. Plast. Surg. 20: 247, Choi, A. K. Oriental blepharoplasty: Nonincisional suture technique versus conventional incisional technique. Facial Plast. Surg. 10: 67, Chen, W. P. Concept of triangular, trapezoidal, and rectangular debulking of eyelid tissues: Application in Asian blepharoplasty. Plast. Reconstr. Surg. 97: 212, Sergile, S. L., and Obata, K. Mikamo s double-eyelid operation: The advance of Japanese aesthetic surgery. Plast. Reconstr. Surg. 99: 662, McCurdy, J. A., Jr. Westernization of the Oriental eyelid. Otolaryngol. Head Neck Surg. 90: 142, Matsunaga, R. S. Westernization of the Asian eyelid. Arch. Otolaryngol. 111: 149, Catalano, P. J., Bergstein, M. J., and Biller, H. F. Comprehensive management of the eye in facial paralysis. Arch. Otolaryngol. Head Neck Surg. 121: 81, 1995.