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Original Investigation
April 5, 2018

Outcomes From Lateral Eyelid Coupling for Facial Paralysis Using the Modified Tarsoconjunctival Flap

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of California, Davis, Sacramento
  • 2Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis
JAMA Facial Plast Surg. Published online April 5, 2018. doi:10.1001/jamafacial.2018.0070
Key Points

Question  Does lateral eyelid coupling in patients with facial paralysis improve quality of life as measured by the Facial Clinimetric Evaluation (FaCE) scale and Ectropion Grading Scale?

Findings  In this cohort study of 16 patients, Moe Ectropion Grading Scale score improved significantly. Quality of life measured using the FaCE scale demonstrated a significant improvement in eye comfort and lacrimal control scores in patients who had undergone radiation therapy but no difference in patients who had not undergone radiation therapy.

Meaning  The combined lower eyelid tightening and tarsoconjunctival flap procedure is effective to obtain corneal protection in patients with facial paralysis.

Abstract

Importance  In the setting of facial paralysis, inadequate eyelid closure and lower eyelid ectropion can lead to corneal exposure and impaired quality of life. Repair of paralytic ectropion is challenging, and an ideal surgical approach for all cases has not been identified.

Objective  To assess the patient-reported outcomes and eyelid position improvement in patients with flaccid facial paralysis undergoing lateral eyelid coupling with a tarsal strip canthoplasty and modified tarsoconjunctival flap to correct eyelid malposition.

Design, Setting, and Participants  Review of medical records of adults with flaccid facial paralysis who underwent a single-stage tarsal strip canthoplasty and modified tarsoconjunctival flap at a tertiary academic center. Inclusion criteria included a minimum of 3 months of follow-up.

Intervention  The lateral upper and lower eyelid are coupled with the hybrid tarsoconjunctival flap.

Main Outcomes and Measures  Patient-reported outcome measures and objective photograph analysis. Preoperative and postoperative Facial Clinimetric Evaluation (FaCE) scores and Moe Ectropion Grading Scale scores were compared. The relationship between radiation therapy (RT) and outcomes was analyzed.

Results  Sixteen patients (8 [50%] female; mean [SD] age at surgery, 71.5 [9.6] years) were identified between January 2014 and August 2017. Twelve (75%) had paralysis from facial nerve sacrifice during cancer ablation. The mean time between paralysis and referral for surgical repair of ectropion was 23 months (range, 0-151 months) and mean follow-up after surgery was 9.8 months (range, 3-39 months). The most common symptom was epiphora, which was significantly reduced after surgery (75% vs 25%; P = .01). Median Moe Ectropion Grading Scale score improved from 3 (interquartile range, 2-3) to 0 (interquartile range, 0-1; P < .001). Quality of life measured using the FaCE scale demonstrated a significant improvement in mean eye comfort (from 18.8 [95% CI, 2.3-35.2] to 47.9 [95% CI, 31.9-63.9]; P = .01) and lacrimal control scores (from 12.5 [95% CI, 0-29.2] to 45.8 [95% CI, 29.3-62.3]; P = .03) in the 6 patients in the RT group, but no difference in the 4 patients in the non-RT group.

Conclusions and Relevance  Ocular symptoms, eyelid appearance, and quality of life were improved after lateral eyelid coupling among patients with flaccid facial paralysis and paralytic ectropion. The tarsoconjunctival flap does limit peripheral vision, but is reversible if dynamic eyelid closure is returned with nerve grafting.

Level of Evidence  4.

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