Improved Function of Orbicularis Oculi by Dynamic Transfer of Contralateral Orbicularis Oculi Muscle in Patients with Facial Palsy.

PURPOSE: The purpose of this study is to introduce the results of a new surgical technique in patients with complete facial nerve palsy using the dynamic muscle transfer of orbicularis oculi muscle (OOM) flap from the contralateral side.
METHODS: This case series presents a new surgical technique in three patients with complete facial palsy and lagophthalmos who were unresponsive to other modalities. In this technique, a rectangular flap of OOM was dissected from the upper lid of fellow eye and transferred to the affected eye through a subcutaneous tunnel over the nasal bridge. The flap was divided into two halves for upper and lower lids. Each half was incised longitudinally to increase the length of the flap and cover the lateral part of the affected eyelids.
RESULTS: Improvement in exposure keratitis, lagophthalmos, and other related symptoms was observed as soon as the 1st week after the surgery. Partial blinking recovered and the operation was uneventful.
CONCLUSION: Muscle flap transfer technique using contralateral OOM for complete facial palsy can be considered as a helpful alternative in patients who are still symptomatic despite conventional treatment modalities. Copyright:

Introduction

The most important ophthalmic consequence of facial nerve palsy is exposure keratopathy due to lagophthalmus. Protecting the eye from exposure keratopathy and corneal ulceration is the priority in the management of facial nerve palsy. This could be achieved by nonsurgical procedures such as lubricating drops and gels, protective glasses, and taping eyelids at night and surgical interventions such as temporary and permanent tarsorrhaphy, insertion of gold weights, lower lid retractor recession,[123] and dynamic procedures such as regional muscle transfer.[4]

Although all of the procedures are beneficial to improve static and/or dynamic movements, they do not restore involuntary blink. Hereby, we introduce a new surgical technique of transferring the contralateral orbicularis oculi muscle (OOM) fibers to regenerate an involuntary blink and improving eyelid closure in patients with complete facial nerve palsy. This technique is a modification of previously mentioned surgical procedures in facial reanimation.[56]

Subjects and Methods

In this case series, consecutive patients with complete facial nerve palsy (House-Brackmann grade 6)[7] who were unresponsive to conventional treatment modalities were included in this study. The present study was approved by the ethical board of Tehran University of Medical Sciences and followed the tenets of declaration of Helsinki of 1975 as revised in 2000. All patients agreed to participate in the study and having their photographs published if necessary, by signing the informed consent form and were followed at least 6 months after surgery. The severity of lagophthalmos and the degree of symptoms related to it, as well as the quality of blink reflex were recorded before and after the operation. Electrophysiological studies of facial nerve including nerve conduction study, blink reflex, and electromyography were performed before the surgery to establish the absence of any re-innervation and repeated 1 month after the surgery. Complications occurring during and after the operation were recorded.

Surgical procedure

The OOM transfer procedure was performed in all patients by a single surgeon [Figure 1 and Supplemental Video 1]. Under local anesthesia, upper eyelid crease of the unaffected side was incised, and a rectangular strip of OOM of upper eyelid was detached from all sides but the medial side. The medial portion remained attached to serve as the pedicle of the flap. Then, on either side of nasal bridge, 10-mm skin incisions similar to the incisions of external dacryocystorhinostomy were made. Subcutaneous tunnels were fashioned by subcutaneous dissection to pass OOM flap from medial canthus and through the subcutaneous tunnel on the nasal bridge to reach the affected side. OOM flap was longitudinally divided into two halves for upper and lower eyelids. Each half was again longitudinally incised from the medial to lateral portion, preserving the lateral 3 mm intact. In this manner, longer muscular flaps that could reach the lateral portion of eyelids of the affected side could be prepared. Then, upper lid crease and lower lid subcilliary incisions were made, followed by longitudinal incisions of affected OOM to provide a gap for suturing the transferred OOM flap by three interrupted 6–0 vicryl sutures. Skin incisions were closed by 6–0 Prolene sutures. Antibiotic ointment and lubricating eye drops were prescribed for patients at the 1st postoperative day. The patients were followed at least 6 months after the surgery.

Figure 1

Schematic drawing of the operation technique (surgeon's view). Top: Orbicularis oculi flap prepared from the upper lid of fellow eye. Middle: The flap is transferred to the involved eye and divided into two halves to cover upper and lower lids. Bottom: Each half is divided through the marked segment, which is rotated to the lateral side

Results

Three patients (two males and one female) were included in our study. All had unilateral complete facial nerve palsy (House-Brackmann Grade 6). The characteristics of the patients are summarized in Table 1.

Table 1

Characteristics of facial palsy patients who underwent contralateral orbicularis oculi muscle transfer procedure

n	Gender	Age (years)	Affected side	Etiology	Previous surgery	Blink		Lagophtalmos (mm)		Visual acuity
						Preoperative	Postoperative	Preoperative	Postoperative	Preoperative	Postoperative
1	Male	76	Left	Metastatic laryngeal carcinoma	Lateral tarsal strip	No blink	Partial blink	8	6	20/100	20/50
2	Male	78	Right	Acoustic neuroma	None	No blink	Partial blink	6.5	3	20/200	20/60
3	Female	70	Left	Acoustic neuroma	Lateral tarsorrhaphy	No blink	Partial blink	7.5	4.5	Hand motions	Hand motions

All patients suffered from the symptoms of lagophthalmos preoperatively and had no blinking. Surgical procedure was done without considerable complications in either eye. However, the patients had eyelid edema and ecchymosis during the 1st postoperative week. The upper lid scar was hidden in upper lid crease and the lower lid scar healed well without significant cosmetic issues. Blinking improved significantly after the surgery in all patients, and improvement was observed as early as the 1st week after the surgery. Symptoms of exposure keratopathy abated markedly and the lagophtalmos decreased partially in our patients [Figure 2]. Visual acuity improved in two of three patients. Electromyography had shown no voluntary muscle activity before the operation [Figure 3a]. One month after the surgery, it showed normal morphology of motor unit voluntary action potential [Figure 3b] in previously paralyzed OOM in all cases.

Figure 2

(a) Photograph of a patient (#2) with complete facial palsy before operation; (b) Photograph of the same patient 9 days after the surgery

Figure 3

(a) Preoperative electromyography of a patient, showing complete loss of activity. (b) Electromyography of the same patient after operation, showing normal morphology of motor unit action potential

The related images and surgical videos of the patients are provided in Supplemental Figures 1–3 and Supplemental Videos 2–4.

Discussion

In this study, all of our patients had their facial nerves sacrificed and had no more chance for recovery. The patients had a history of a single oculoplastic procedure to correct lagophtalmos and exposure keratopathy. However, they still remained symptomatic due to absent blinking and lagophtalmos. After surgery, our patients experienced a remarkable decrease in the severity of symptoms of exposure and the need for lubrication.

Transfer of OOM to the paralyzed side has been tried to provide either static[8] or dynamic[56] support to eyelid closure in facial palsy patients. Apparently, transfer of OOM from the fellow eye has the potential to provide functional muscle and dynamic support, while other authors have transferred OOM from the upper eyelid of the paralytic side to the lower eyelid of the same side to provide static support to the lower eyelid orbicularis oculi.[8]

A previous study by Sadiq and Dharmasena[5] assessed the outcome of dynamic muscle transfer with an OOM flap from the contralateral side to the paralyzed side in patients with facial nerve palsy. An important modification in our method compared to the mentioned study was that we provided a longer muscular flap to cover almost the entire length of the affected eyelids, while in the study of Sadiq and Dharmasena[5] only the medial third of affected eyelids were sutured to OOM flap. The longitudinal dissection of each slip of the superior and inferior flaps enabled us to lengthen the muscular flap and cover a larger length of the eyelids. The results of the present study and Sadiq and Dharmasena[5] were similar; although complete blink was achieved in none of patients, partial blinking could still subside the sign and symptoms of the patients and decrease discomfort. Furthermore, in our study, involuntary blink reflex on the affected side occurred without conscious effort. Sadiq and Dharmasena[5] concluded that it is difficult to objectively assess the improvement because of the effect of multiple previous procedures. In the present study, however, patients had just one surgical procedure before our intervention. Therefore, the probable contribution from previous procedures is less likely to interfere with the findings of our study.

In a previous experimental study by Hockman et al.,[6] four cats underwent a similar procedure of contralateral OOM for the management of iatrogenic facial palsy. There was remarkable improvement in reflex and spontaneous blinking, eyelid closure, and strength of orbicularis oculi. Apart from the studies by Hockman et al.[6] and Sadiq and Dharmasena,[5] we did not find other studies that successfully applied contralateral OOM flaps for facial palsy patients.

This study had certain limitations. Small sample size and short follow-up period were the most important. Larger studies with longer follow-up would provide more accurate evaluation of the outcome of this surgical technique.

Conclusion

It seems that OOM transfer procedure has cosmetically and functionally acceptable outcomes and can be proposed for patients with complete facial nerve palsy suffering from persistent symptoms by improving forced and spontaneous blinking.

Declaration of patient consent

The authors certify that they had obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images, and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

(a) Open and closed eye photograph of a patient (1) with complete facial palsy before the operation; (b) Open and closed eye photograph of the same patient 12 days after the surgery

(a) Open and closed eye photograph of a patient (2) with complete facial palsy before operation; (b) Open and closed eye photograph of the same patient 9 days after the surgery

Open and closed eye photograph of a patient (3) with complete facial palsy before the operation; (b) Open and closed eye photograph of the same patient 14 days after the surgery